June 27, 2022                CERTIFIED MAIL

Blake Elliott, Authorized Agent

Aldrich Boarding Care Home, LLC dba Bridges MN

1923 University Ave W

Saint Paul, MN 55104

License Number: 1079030 (Home and Community-Based Services)

Maltreatment Investigation Report Numbers: 202109523, 202109897, 202200273, and 202200414

License Complaint Report Number: 202203077

ORDER OF LICENSE REVOCATION,

DETERMINATIONS OF MALTREATMENT, AND

FAILURE TO REPORT MALTREATMENT

Dear Blake Elliott:

You are hereby notified that the Commissioner of the Department of Human Services (DHS) is revoking your Bridges MN, Home and Community-Based Services license, number 1079030. The revocation is based on new substantiated findings of maltreatment, continued non-compliance with relevant Minnesota Statutes and Rules, and continued non-compliance with terms of the Bridges MN conditional license.

The revocation goes into effect on Thursday, July 12, 2022, at 6:00 p.m. to allow fifteen days for you to inform the Commissioner whether you intend to appeal the license revocation explained below.

Background information:

Aldrich Boarding Care Home, LLC, dba Bridges MN (“Bridges MN”) operates licensed home and community based services (HCBS) programs under license number 1079030. Under this license, Bridges MN provides services to individuals in 48 Community Residential Services (CRS) facilities, 7 Integrated Community Settings (ICS), and in their own or family homes and the community. While each CRS has a unique license number and each ICS is provided at a specific address, all services are provided under the Bridges MN license.

On March 10, 2020, Bridges MN was placed on conditional status due to serious licensing violations determined as a result of a licensing review conducted on November 21, 2019, as well as the nature, chronicity, and severity of these violations and the impact on the health, safety, and rights of the persons served at the program. These violations included, in part, knowingly withholding relevant information from the Commissioner, denying the Commissioner access to records, failing to ensure the health, safety, and rights of persons receiving services, and failing to comply with background study requirements.

Bridges MN appealed the March 10, 2020, Conditional License, and the terms of the conditional licnese were stayed pending the outcome of the appeal. On July 1, 2020, the Order of Conditional License was affirmed and became effective.

DHS conducted licensing reviews during the period of the conditional license, as well as reviewing and responding to licensing compaints and maltreatment reports. Between July 1, 2020, and June 27, 2022, DHS identified a pattern of non-compliance with Minnesota Rules and Statutes and with the terms of the conditional license.

Between July 1, 2020, and June 27, 2022, the following resulted from licensing reviews:

· On September 17, 2020, a review of submissions for conditional license was completed. Noncompliance with one of the terms was found as Bridges MN did not develop detailed plan on how they would come into compliance with the citations in the order. A correction order with additional corrective action was issued.

· December 1-3, 2020, a licensing review was conducted. This resulted in 10 additional violations, with 5 being repeat violations. This licensing review also resulted in an order to pay a fine for four background study violations.

· March 25-26, 2021, a licensing review was conducted. This resulted in 9 additional violations, with 3 being repeat violations. Additionally, there were 7 areas of noncompliance with conditional license.

· August 31-September 3, 2021, a licensing review was conducted. This resulted in 24 additional violations, with 17 of those being repeat violations.

· January 10-14, 2022, a licensing review was conducted. This resulted in 18 additional violations, with 16 of those being repeat violations. A background study violation was also determined and included in this order. See Section IV, citation 18 for further detail.

· April 24-May 9, 2022, a licensing review was conducted. The results from this review are included in this order. Thirty violations were identified, with twenty-one of those being repeat violations. See Section IV, citations 19 through 48 for further details.

Additionally, between July 1, 2020, and June 27, 2022, there were 22 violations identified (6 repeat) as a result of licensing complaint investigations, maltreatment investigations, and review of submissions for serious injury reports.

I. Determinations of Maltreatment

A. Maltreatment Report Number 202109523, occurring at Bridges MN Jensen, located at 23900 Jensen Avenue North, Forest Lake, Minnesota, CRS license number 1092294:

It was reported that a staff person (SP2) had a sexual relationship with a vulnerable adult (P3). During the investigation, information was received that on one occasion the staff person choked the vulnerable adult; and that on multiple occasions the staff person purchased, possessed, used, and was under the influence of cocaine while driving and providing other services to the vulnerable adult. DHS investigated the report as alleged maltreatment by neglect.

Based on the maltreatment investigation, DHS determined that Bridges MN was responsible for neglect of the vulnerable adult. See the enclosed Investigation Memorandum Report Number 202109523 for more information.

B. Maltreatment Report Number 202200273 occurring at Bridges MN Pearl Lake, located at 18641 State Highway 15, Kimball, Minnesota, CRS license number 1090335:

It was reported that two vulnerable adults (P4 and P5) had sexual contact with one another on more than one occasion. During the investigation, it was also reported that several staff persons were found to be sleeping and/or lying down and leaving the facility while on shift. P4 required 24 hour supervision and 1:1 care due to his/her specific vulnerabilities.

Based on the maltreatment investigation, DHS determined that Bridges MN was responsible for neglect of the vulnerable adults. See the enclosed Investigation Memorandum Report Number 202200273 for more information

C. Maltreatment Report Number 202200414, regarding a vulnerable adult who lived in his/her own home, and received services from Bridges MN:

It was reported that staff called 9-1-1 for a vulnerable adult (P6) who was sick, and when emergency medical services arrived, they found the vulnerable adult lying in feces and vomit, and with “mottled” skin. The vulnerable adult was taken via ambulance and died shortly thereafter. Concerns were raised regarding the living conditions at the vulnerable adult’s apartment, and the overall care prior to the vulnerable adult’s death.

Based on the maltreatment investigation, DHS determined that Bridges MN was responsible for neglect of the vulnerable adult. See the enclosed Investigation Memorandum Report Number 202200414 for more information.

Legal Authority: Minnesota Statutes, sections 626.557, subdivision 9c and 626.5572, subdivision 17 (a) and (b).

II. FAILURE TO REPORT MALTREATMENT

Based on the maltreatment investigations, DHS determined that staff persons, including administrative staff persons, had knowledge of incidents of alleged maltreatment, but did not make a report as required.

A. Maltreatment Report Number 202109523: Ongoing, between November 2020 and January 23, 2021, multiple staff persons had concerns about a staff person’s interactions and boundaries with a vulnerable adult and shared their concerns with two supervisory staff persons, a house supervisor and a director, but a report was not made as required. The Department received the report on October 12, 2021.

B. Maltreatment Report Number 202109897:

i. Regarding Allegation One: On October 18, 2021, a vulnerable adult told two supervisory staff persons at the facility that a staff person punched the vulnerable adult in the genitals but a report was not made as required.

ii. Regarding Allegation Two: A supervisory staff person said that in late summer or early autumn of 2021, two vulnerable adults “accused [a staff person] of touching them sexually,” including touching their buttocks. The supervisory staff person said that, at that time of hearing the report, s/he told the administrator of the allegations and was told s/he did not need to document them because s/he did not directly witness the incident, and because the two vulnerable adults each declined when asked if they wanted to make a report. A report was not made as required. The Department was made aware of the report during the investigation of Allegation One.

Legal Authority: Minnesota Statutes, section 626.557, subdivision 3 and Minnesota Statutes 245A.65, subdivision 1.

Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4), a license holder shall forfeit $1,000 for each determination of maltreatment of a vulnerable adult and $200 for each occurrence of a violation of law or rule governing matters of health, safety, or supervision. However, because the Commissioner is imposing a more severe licensing sanction, Bridges MN is not being fined for the maltreatment determinations or for failing to report maltreatment as required. If the revocation is rescinded upon appeal, DHS may impose the fine at that time.

III. ORDER OF LICENSE REVOCATION

Under Minnesota Statutes, section 245A.07, subdivisions 1 and 3, the Commissioner may revoke a license if a license holder fails to comply fully with applicable laws or rules. When applying a licensing sanction, the Commissioner shall consider the nature, chronicity, or severity of the violation of law or rule and the effect of the violation on the health, safety, or rights of persons served by the program.

A. COMMISSIONER’S EVALUATION

In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of persons served by your program, and information about the qualifications of caregivers and staff persons that are working in your program. DHS has determined that revocation of your license is appropriate based on the nature, severity, and chronicity of violations determined by DHS as detailed below, the recent licensing violations detailed in section IV of this order, and the program evaluation.

Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6.

Nature – The program was operating under a conditional license as of July 1, 2020.

Violations cited in the Order of Conditional License include violations of law or rule affecting the health, safety, or rights of individuals served by the program. These violations have continued through to this revocation oder and include:

o Failure to ensure the exercise and protection of a person’s service-related and protection-related rights, including, but not limited to, the right to be free from maltreatment

o Failure to meet health service needs consistent with the person’s health needs

o Failure to provide services in response to the person’s identified needs, interests, preferences, and desired outcomes

o Failure to designate a qualified and competent staff person(s) to fulfill the responsibilities for coordination and evaluation of individual service delivery and program management and oversight

o Failure to establish, enforce, and maintain policies and procedures related to health and welfare

Severity – Many of the violations that have led to the revocation of your license relate to the health and safety of persons served within your program and were have been identified in the order of conditional license. Subsequent correction orders following the order of conditional license continue to identify violations realted to the health and safety of the persons you serve.

Chronicity – Your program received its license on September 9, 2015. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history:

o December 27, 2016 Correction Order:  14 violations

o January 26, 2017 Order to Pay a Fine:  26 background study violations

o September 28, 2017 Determination of

Maltreatment and Order to Pay a Fine:  Maltreatment determination and 3 violations

o October 11, 2017 Correction Order:    1 violation

o October 11, 2017 Determination of

Maltreatment and Order to Pay a Fine:  Maltreatment determination and 4 violations

o December 29, 2017 Correction Order:  1 violation

o February 28, 2018 Correction Order:   1 violation (repeated violation)

o June 22, 2018 Correction Order:    2 violations

o July 2, 2018 Correction Order:    1 violation

o September 13, 2018 Correction Order:  2 violations (1 repeated violation)

o November 1, 2018 Determination of

Maltreatment and Order to Pay a Fine:  Maltreatment determination and 1 violation

o January 3, 2019 Correction Order:     1 violation

o March 22, 2019 Correction Order:     5 violations (1 repeated violation)

o April 9, 2019 Correction Order:    1 violation

o May 1, 2019 Correction Order:    4 violations (1 repeated violation)

o May 2, 2019 Determination of

Maltreatment and Order to Pay a Fine:  Maltreatment determination

o May 2, 2019 Correction Order:     1 violation

o May 10, 2019 Correction Order:    1 violation

o June 14, 2019 Correction Order:     31 violations (14 repeated violations)

o June 14, 2019 Correction Order:    1 violation

o July 26, 2019 Correction Order:    10 violations (3 repeated violations)

o July 30, 2019 Correction Order:    1 violation

o August 8, 2019 Correction Order:    1 violation

o August 13, 2019 Correction Order:     1 violation

o August 28, 2019 Correction Order:     1 violation (repeated violation)

o December 4, 2019 Correction Order:   2 violations

o December 10, 2019 Correction Order:  3 violations

o December 27, 2019 Order to Pay a Fine:  Failure to report maltreatment

o December 27, 2019 Correction Order:  6 violations

o December 31, 2019 Correction Order:  1 violation

o February 7, 2020 Correction Order:    1 violation

o February 21, 2020 Correction Order:    1 violation

o March 10, 2020 Conditional License:    10 violations (7 repeated violations)

effective July 1, 2020

o March 12, 2020 Correction Order:    1 violation

o March 12, 2020 Correction Order:    2 violations (1 repeated violation)

o July 8, 2020 Correction Order:    1 violation

o August 14, 2020 Correction Order:    1 violation

o August 19, 2020 Correction Order:    2 violations (2 repeated violations)

o October 7, 2020 Correction Order:    1 violation (repeated violation)

o October 27, 2020 Notice of Noncompliance

and Correction Order:        9 violations

o December 31, 2020 Correction Order:  1 violation (repeated violation)

o January 6, 2021 Correction Order:    1 violation

o February 5, 2021 Correction Order:    10 violations (5 repeated violations)

o April 2, 2021 Correction Order:    1 violation

o April 15, 2021 Correction Order:    3 violations

o May 20, 2021 Notice of Noncompliance

and Correction Order:        9 violations (3 repeated violations)

o May 25, 2021 Order to Pay a Fine:    4 background study violations

o September 14, 2021 Correction Order:  1 violation

o September 17, 2021 Correction Order:  1 violation

o October 15, 2021 Correction Order:    2 violations

o November 9, 2021 Correction Order:    1 violation (repeated violation)

o December 6, 2021 Notice of Noncompliance

with Terms of Conditional License:    24 violations (17 repeated violations)

o December 17, 2021 Correction Order:  2 violations

o February 25, 2022 Correction Order and

Noncompliance with Terms of a

Conditional License:        18 violations (16 repeated violations)

o June 3, 2022 Correction Order:    2 violations

o June 8, 2022 Correction Order:    2 violations

o June 27, 2022 Revocation (this order):  48 violations (21 repeated violations)

3 maltreatment determinations

The Commissioner has considered the nature, chronicity, and severity of the licensing violations and has determined that revocation of the Bridges MN HCBS license is warranted. In addition, the Revocation is further supported by the bases provided below.

B. FAILURE TO FOLLOW LICENSING RULES AND STATUTES

DHS determined that Bridges MN failed to fully comply with the laws and rules that apply to licensed HCBS programs. Details on the specific licensing violations determined by DHS are provided in Section IV below.

Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(1)

C. CONDITIONAL LICENSE VIOLATIONS

DHS has determined that you failed to follow the terms of the Order of Conditional License that is was effective on July 1, 2020. Term 4 of the Order of Conditional License required you to develop and submit a detailed plan on how your would come into compliance with applicable statutes and rules. On October 27, 2020 you were notified in a Notice of Non-Compliance and Correction Order that you had failed to comply with Term 4 of the Order of Conditional License. DHS has completed monitoring activity since that time and has determined that you continue to fail to comply with Term 4. This is summarized in Section A above regarding chronicity and supported Section IV below for the most recent licensing violations.

Legal Authority: Minnesota Statutes, sections 245A.06, subdivision 3; and 245A.07, subdivision 3(a).

D. FALSE OR MISLEADING INFORMATION

DHS determined that you knowingly withheld relevant information or provided false or misleading information related to your compliance with licensing rules and laws. During a licensing review conducted from April 25, 2022, through May 6, 2022, the following occurred to support DHS’ determination:

· P6’s record was reviewed and contained a document titled, “Meeting Delay Form.” It was created on April 25, 2022, the first day of the licensing review.

· The document stated that the 45-day meeting for P6 was delayed because P6’s legal representative and case manager preferred to align the 45-day meeting in February to P6’s new intake meeting in March 2022.

· A DHS licensor contacted P6’s case manager to verify the documentation. P6’s case manager stated that the license holder contacted them via email on February 22, 2022 about setting up a 45-day meeting. There was communication back and forth via email regarding availability and later that day the license holder, not the case manager, proposed combining the 45-day meeting and the intake meeting.

· The case manager did not prefer P6’s 45 day meeting to be delayed and did not request that the 45-day meeting be delayed.

Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(3).

IV. LICENSING VIOLATIONS  

Licensing violations determined as a result of Maltreatment Report Number 202109523

1. Citation: Minnesota Statutes, section 245D.09, subdivision 4, clause (5).

Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide and ensure completion of orientation training as required.

It was determined that SP1 was hired at the facility on January 3, 2020, and provided direct contact services on or before November 1, 2020. The license holder failed to provide training to SP1 on the Reporting of Maltreatment of Vulnerable Adults act, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment within 72 hours of SP1 first providing direct contact services. The license holder failed to provide this training to SP1 at any time during his/her employment at the facility. (This violation was also determined for report 202109897.)

2. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraphs (a) and (c).

Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required.

It was determined that the license holder failed to provide orientation to individual service recipient needs to SP1 prior to SP1 having unsupervised contact with P3. SP1 had unsupervised contact with P3 on or before November 1, 2020; but was not provided training on P3’s, individualized plans during his/her employment at the facility.

Licensing violations determined as a result of Maltreatment Report Number 202109897

3. Citation: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6).

Violation: The license holder did not ensure P1 and P2 were treated with courtesy and repect.

a. It was determined that S12 talked about persons of another gender in a sexual way around P1 and P2 including “getting with” 15 and 18 year old persons of another gender “because they’re young.” P2 said when s/he told S12 s/he did not want to talk about this, S12 told P2 s/he “must be gay,” which made P2 feel “upset;” and P1 said that s/he was a child sexual abuse survivor and s/he perceived S12 as “unsafe” after such conversations.

b. It was determined that SP1 yelled at P1 and P2, saying things such as “Do you think this job is easy?” “Leave me alone!” and, “What is [P2’s] problem.” SP1 also spoke in manner that was “rude and “not very nice.

4. Citation: Minnesota Statutes, section 245D.06, subdivision 1, paragraph (b).

Violations: For two persons served (P1 and P2), the license holder did not maintain information about an incident of alleged maltreatment.

It was determined that on an unspecified date in late summer of early autumn of 2021, a supervisory staff person became aware of an allegation of “sexual touching” of P1 and P2 by a staff person. However, the incident was not documented. (This incident was also not reported as suspected maltreatment as required, which is cited in section II.)

For P1, the license holder did not report an incident to the person’s designated emergency contact and case manager within 24 hours of discovery or receipt of information that an incident occurred.

On October 18, 2021, two supervisory staff persons became aware of an incident of alleged maltreatment that occurred on October 16, 2021. However, P1’s designated emergency contact and case manager were not notified of the incident until October 29, 2021.

5. Citation: Minnesota Statutes, section 245A.04, subdivision 13, paragraphs (b) and (d).

Violation: For P2, the license holder did not ensure separation of funds of persons served by the program from funds of the license holder, the program, or program staff; and license holders and program staff used funds of persons served by the program to purchase items for which the facility was already receiving public or private payments.

It was determined that according to P2’s coordinated service and support plan, the facility was assigned responsibility to provide transportation to P2 when s/he accessed the community for various reasons. However, on at least one occasion, and likely two or three occasions, P2 purchased fuel for a facility vehicle. P2 was later reimbursed, although it could not be determined whether P2 was fully reimbursed, or the timeline of P2’s reimbursement, due to insufficient documentation.

6. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), clause (3).

Violation: The license holder did not monitor the implementation of policies and procedures.

It was determined that SP1 wore undergarments while providing services to P1 and P2.

7. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For P2, the license holder did not provide services as assigned in the coordinated service and support plan.

It was determined that on P2 received residential and employment support services from the license holder. According to P2’s coordinated service and support plan, the residential facility was assigned responsibility to provide transportation to P2, including transportation to and from his/her job. However, on multiple occasions, P2 was unable to attend his/her job because the facility lacked sufficient staffing to transport P2 to work. This resulted in lost wages for P2. In addition, one of P2’s employment support services goals was to attend work 100% of the time, so lack of transportation was also detrimental to P2 achieving his/her therapeutic goals.

Licensing violations determined as a result of Maltreatment Report Number 202200273

8. Citation: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a).

Violation: The license holder did not provide services in response to two individuals’ (P4’s and P5’s) coordinated service and support plan addendums (CSSPA).

a. P4’s CSSPA stated:

· P4 had 1:1 staffing 24/7 and 40 hours of shared staffing to ensure his/her and others safety within the home;

· P4’s Individual Abuse Prevention Plan also stated that P4 was susceptible to sexual and physical abuse;

· P4 had a history of sexual aggression and staff would redirect as they are able and staff would be with P4 in the community and at home;

· staff would be with P4 in the community and in the home; and

· the scope of services based on the CSSPA dated April 1, 2021 stated P4 was provided “positive behavioral supports and training over and above 245D requirements.”

b. P5’s CSSPA stated:

· P5 required a caregiver be present at all times to assist P5;

· the license holder was responsible for meeting P5’s quality of life indicators such as health and safety; and

· P5 was susceptible to sexual and physical abuse.

c. Information was provided by a designated facility reporter (S9) and a regional executive director (S10) that after review of camera footage, between the dates of December 31, 2021 and January 10, 2022, staff failed to provide services as required in P4 and P5’s CSSPA:

· On December 31, 2021, from 1 a.m. to 6:40 a.m., a staff person (S1) appeared to be asleep on the couch;

· On January 1, 2022 from 9:33 a.m. to 12:00 p.m., a staff person (S6) was laying on the couch. From 6:00 p.m. to 8:00 p.m., S6 appeared to be asleep on the couch. At midnight, S1 made a bed on the couch and appeared to be asleep until 8:00 a.m.;

· On January 2, 2022 at 2:00 a.m., S1 appeared to be asleep on the couch for an unknown amount of time. At 11:00 p.m., S6 laid on the couch and appeared to be asleep until 8:00 a.m.

· On January 3, 2022, at 1:45 a.m., S6 was seen lying on the couch, asleep until 7 a.m.

· On January 6, 2022, at 11:51 p.m., a staff person (S7) left the facility and returned at 2:08 a.m. with food.

· On January 7, 2022, from 1 to 7 a.m., a staff person (S8) laid on the couch and appeared to be sleeping.

· On January 9, 2022, S1 and S2 appeared to be asleep in the living room from 2:15 a.m. to 8 a.m.

· On January 10, 2022, from 2:21 to 6:23 a.m., S1 appeared to be asleep on the couch.

According to law enforcement information, P4 and P5 had sexual contact on an unknown date, per P5’s medical records.

9. Citation: Minnesota Statutes, section 245D.081, subdivision 2, paragraph (a).

Violation: The license holder did not ensure the designated coordinator and designated manager provided program coordination and evaluation as required.

a. The designated coordinator(s) identified by the license holder (LH) failed to provide supervision, support, and evaluation of the activities that include:

· oversight of the license holder’s responsibilities as assigned in the person’s coordinated service support plan and the coordinated service support plan addendum;

· taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; and

· instruction and assistance to direct support staff implementing the coordinated service support plan and service outcomes, including direct observation of service delivery sufficient to assess staff competency.

See citations 1 and 3 as evidence of the failures of the designated coordinators identified by the license holder.

b. The designated manager(s) identified by the license holder (LH) failed to provide program management and oversight of the services provided by the license holder that include:

· maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (b);

· ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2;

· evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04;

· ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5;

· ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

See citations 1 and 3 as evidence of the failures of the designated managers.

10. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For eight of ten staff persons whose record was reviewed (S1-S8), the license holder did not provide orientation to the individual service recipient needs as required.

· According to S11, all staff working with in Bridges MN Pearl Lake were required to have been provided orientation as required to P4 and P5 individual service recipient needs:

· During collection of information from the facility and through email communication with S10, there was no documentation showing S2 and S5 were provided training as required prior to unsupervised direct contact for P4; and

· During collection of information for a maltreatment investigation and through email communication with S10, there was no documentation showing S1-S8 were provided training as required prior to unsupervised direct contact with P5.

Licensing violations determined as a result of Maltreatment Report Number 202200414

11. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5) and paragraph (b), clauses (8) and (9).

Violation: The license holder did not ensure a person’s protection-related rights include the right to receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site and the right to have a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects, and free from hazards that threaten the person’s health or safety.

Information was provided by emergency medical services, law enforcement, and P6’s family members that on January 17 and 25, 2022, P6’s apartment contained dried feces, vomit, and urine.

12. Citation: Minnesota Statutes section 245D.05, subdivision 2, paragraph (a), clause (5).

Violation: The license holder did not notify the prescriber or nurse of any concerns with P6’s medication or treatment, including side effects, effectiveness, or a pattern of the person refusing to take the medication or treatment as prescribed.

Information was provided that P6 routinely declined to take his/her medications; and there was no information this was ever communicated to the prescriber or nurse.

13. Citation: Minnesota Statutes section 245D.05, subdivision 4, paragraph (b), clause (2).

Violation: The license holder did not notify a persons’s (P6’s) legal representative (LR) of P6’s refusal or failure to take or receive medication or treatment as prescribed.

The LR said that s/he was supposed to be receiving weekly updates from the facility regarding P6, including if P6 missed any medications. However, during the eight months P6 lived at the facility, the LR had only received two or three weekly updates and was never notified of any missing medications.

14. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For P6, the license holder did not provide services as assigned in the coordinated service and support plan.

Information was provided that P6 received 24 hour in home supports from the license holder. According to P6’s coordinated service and support plan, the facility was assigned responsibility to assist the VA by doing typical household chores andmaintance, managing self care and home management, and providing light housekeeping. When the VA was unwilling to clean the area, staff will do it for P6. Bridges MN failed to implement P6’s plan as documented by the condition of P6’s apartment.

15. Citation: Minnesota Statutes 245D.09, subdivision 2.

Violation: The license holder did not ensure adequate supervision of staff providing direct support to ensure the health, safety, and protection of the rights of P6 and implementation of the responsibilities assigned to the license holder in P6's coordinated service and support plan or coordinated service and support plan addendum.

Information was provided by emergency medical services, law enforcement, and P6’s family members that on January 17 and 25, 2022, P6’s apartment contained dried feces, vomit, and urine. The staff present said that they “sometimes” helped clean the apartment and “sometimes did not.“

Licensing violations determined as a result of Licensing Complaint Report 202203077

16. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clause(s) (8) and (9).

Violation: The license holder did not ensure protection related rights for P1—P4.

During a site visit conducted on June 6, 2022, the license holder failed to ensure the setting was clean and free from accumulation of dirt, garbage, peeling paint, insects and a setting that is free from hazards that threaten the person’s health and safety. Bridges MN has financial or business relationship to the entity that owns, rents, or leases the property or units, or is otherwise responsible for the upkeep, protection, or maintenance of this property.

During a walkthrough of the building, a DHS licensor noted the following:

· fly paper strips with insects in common areas

· dirty carpeting and floor runners

· accumulated dirt on the floors and stairs

· heating units that appeared to be broken and hanging on the floor

· a unit occupied by P1 with no carbon monoxide detector

· an entry way rug with holes that also had corners that posed a tripping hazard

· cracked and missing tiles on the floor

· an interior door that had a large piece cut open and exposed

· multiple areas with exposed wiring within units occupied or used by persons served by Bridges MN.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019, December 31, 2019, May 20, 2021 and October 15, 2021.

17. Citation: Minnesota Statutes, section 245D.081, subdivision 3

Violation: The license holder did not ensure program management and oversight as required.The license holder failed to ensure the designated manager provided program management and oversight when the exercise and protection of P1—P4’s rights were not upheld.

The designated manager was responsible for:

· maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); and

· evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress toward accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019, December 27, 2019, March 12, 2020 and May 20, 2021.

Licensing violation determined as a result of a licensing review conducted on January 10 – 14, 2022

18. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g).

Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not submit a completed background study request to DHS using the electronic system known as NETStudy 2.0 before SP3 and SP4 began positions allowing direct contact in a licensed program.

a. SP3 began working in a position allowing direct contact with persons served by the program on December 6, 2021 and had direct contact with persons served by the program on December 7, 2021. However, the license holder did not initiate a background study to DHS until January 10, 2022.

b. SP4 began working in a position allowing direct contact with persons served by the program on August 1, 2020. However, the license holder did not initiate a background study to DHS until August 12, 2020.

Licensing violations determined as a result of a licensing review conducted on April 24, 2022 through May 9, 2022

COMMISSIONERS ACCESS

19. Citation: Minnesota Statutes, section 245A.04, subdivision 5, paragraph (a).

Violation: During a compliance monitoring visit conducted from April 25—May 9, 2022, the license holder did not allow access to documents and records, including records maintained in electronic format as required.

· May 9, 2022:

o By email, DHS requested access to 19 staff records that worked specifically with P25 to be sent via secure email.

o The license holder received this request and responded they would complete the request.

o DHS submitted an email to SP30 stating they no longer needed access to Google Drive and would no longer have the ability to access the information. All additional information would need to be sent through a secure email to DHS licensors.

· May 16, 2022:

o By email, DHS requested the information a second time as the license holder had not submitted the documented requested. DHS stated the information would need to be submitted via secure email, no later than 12:00 p.m. on May 16, 2022.

o The license holder responded stating they uploaded the requested documents to the license holder’s Google Drive account on May 9, 2022.

o Bridges MN emailed stating they could not find training for six staff persons that worked with P25.

o DHS requested information on whether or not SP11—SP13 worked with P25.

o At 12:12 p.m. the license holder stated, “We have staff who have completed the training and we are working on getting those documents sent to you. With that being said, we are not able to meet the deadline..[of 12:00PM]” and requested an extension.

Based upon the information above, the license holder failed to ensure Commissioner access to documents and records, including electronic records when requested.

The request for access to staff records to monitor compliance for staff training, allows DHS to review for staff training related to the services, health needs and any financial oversight of the program. Based upon the license holder’s failure to provide access, DHS was unable to determine whether or not the program adequately trained staff to work with P25. It should also be emphasized, that the license holder was also unable to locate the training records to determine whether the staff were provided orientation and annual training on the service and health needs of P25.

BACKGROUND STUDY REQUIREMENTS

20. Citation: Minnesota Statutes, section 245C.07, paragraph (a), clause (1).

Violation: For one staff person whose record was reviewed (SP23) the license holder did not comply with the requirements under section 245C.07 regarding the sensitive information person as required.

The license holder owned multiple programs and had at least two individuals designated to receive sensitive background study information.  The license holder failed to designate one individual to receive sensitive background study information for all of their programs. SP23 began working in a position allowing direct contact with persons served by the program on September 20, 2021. The license holder did not submit SP23’s background study under this license when SP23 first began a position allowing direct contact.  The license holder submitted SP23’s background study for three other programs that had a different sensitive information person on September 20, 2021.  The license holder later affiliated SP23’s background study to this program on December 22, 2021.

RECORD REQUIREMENTS

21. Citation: Minnesota Statutes, section 245D.095, subdivision 1.

Violation: The license holder did not ensure that the content and format of service recipient, personnel and program records were uniform and legible according to this chapter.

During the licensing review, the license holder stored staff, service recipient and program records in Google Drive, Therap, on personal computers, and in paper records. The license holder had no uniform organization of records, which varied from region to region.

Staff working with vulnerable adults and children must understand the needs of the persons and how they should provide services. This information is required to be maintained in a uniform fashion, as staff must be knowledgeable about where this information is and how they can access records as needed. Throughout the review, Bridges MN was unable to provide documents requested by DHS, as they were unable to locate where documents were.

When staff are unable to obtain record information that references the needs of the vulnerable adult or child, it is inherently connected to the health and safety of the person.

Repeat Violation: The license holder was cited for a similar violation in a correction order dated June 14, 2019.

22. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a).

Violation: For six staff persons whose records were reviewed (SP9, SP10, and SP23-SP26), the license holder did not maintain personnel records as required.

c. SP10, SP23, SP25 and SP26’s personnel records had dates listed for the completion of the orientation to individual service recipient needs that were not congruent with other information in their personnel records. DHS was unable to determine when the orientation took place. The license holder failed to accurately document the date the orientation to individual service recipient needs training was completed in SP10, SP23, SP25, and SP26’s personnel records.

d. The license holder failed to document the number of hours per training per subject area in SP9, SP10, and SP23-SP26’s personnel records.

Under this subdivision, the license holder is required to document and maintain staff training records to show when staff received orientation to the programs requirements, orientation to the individual service recipient’s needs, and annual training. The training, that is required by section 245D.09 ensures staff are trained on the program policies, basic first aid, the person served health needs, their medication and if applicable how to operate medical equipment. Based upon the review of records indicated above, DHS was unable to determine if staff received the training as required. Bridges MN failed to maintain documentation in the staff record to show training was complete as required.

Repeat Violation: The license holder was cited for a similar violation in a correction order dated February 28, 2018.

POLICIES AND PROCEDURES

23. Citation: Minnesota Statutes, section 245D.11, subdivision 2, paragraphs (3) and (4).

Violation: The license holder failed to enforce policies and procedures that promote health and welfare.

a. During a visit to the home of P15, a licensed community residential setting facility, MN Bridges Pearl Lake, license number 1090335, a DHS licensor observed that the van, which was owned and maintained by the license holder, was dirty and unkept. One of the back door handles was broken and unable to be opened from the outside. During an interview with P15, P15 informed the DHS licensor that they got scared riding in the van because the doors to the van fly open unexpectedly while driving. When the DHS licensor asked the staff person that was present if this was true, the staff person replied “yeah, pretty much.” P15 informed the DHS licensor that these issues have been reported to members of the management team.

· The license holder’s Policy and Procedure on Safe Transportation stated, “The Residential Supervisor or Transportation Manager or Designee will ensure the safety of vehicles, equipment, supplies, and materials owned or leased by the company and will maintain these in good condition. Standard practices for vehicle, equipment, supplies, and materials maintenance and inspection will be followed.”

· The license holder failed to enforce their policies and procedures that promote health and welfare, regarding safe transportation.

b. During a visit to the home of P11 at approximately 9:00am, a DHS licensor observed 12:00 p.m. and 2:00 p.m. medications were signed off in the medication administration record (MAR) with staff initials. The MAR Documentation Legend in the front of the book stated, “Your initials means the client took the medication.” During an interview with the staff person at the home, the staff person stated that the medications were signed because person served was going to be leaving later so the medications were packaged to be sent with the person. The staff person stated they were unaware that packaged medications should be documented to reflect that they were packed and not documented as being administered.

· The license holder failed to enforce their policies and procedures that promote health and welfare regarding Medication Administration.

Minnesota Statutes, section 245D.11, subdivision 2 require license holders to establish, enforce and maintain policies and procedures that directly affect health and safety of persons served within their program. During the review, Bridges MN failed to enforce their safe transportation policy when discovered that a van was not safe to use in transporting vulnerable adults. It was determined that this was the only van for this home. Bridges MN is also responsible for enforcing safe medication assistance and administration policies, which ensure staff accurately, administer or assist vulnerable adults and children with medications prescribed by their doctor. This safe medication assistance and administration policy also ensures staff are accurately documenting the administration of medication to ensure the vulnerable adult is taking medications and treatments as prescribed.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated March 10, 2020, February 2, 2021, November 9, 2021, and February 25, 2022.

SERVICE RECIPIENT RIGHTS

24. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For one person whose record was reviewed (P20), the license holder did not provide a written notice that identified the service recipient rights and an explanation of those rights as required.

The license holder failed to provide a written notice that identified the individual’s rights and an explanation of those rights within 5 days of service initiation. P20’s services were initiated on May 20, 2021, however; a written notice of P20’s rights was not provided until July 26, 2021.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019 and February 25, 2021.

25. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For one person whose record was reviewed (P20), the license holder did not inform and provide copies of the policies and procedures that affect a person’s rights under section 245D.04, within five working days of service initiation as required.

Services were initiated for P20 on May 20, 2021. The license holder failed to inform and provide copies of the following policies and procedures to P20’s case manager within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy policy and procedure.

Minnesota Stautes, section 245D.04 identifies and explains the rights of service recipients when receiving a 245D service. A person receiving home and community-based services is afforded service-related rights and protection related rights. At the time of service initiation, vulnerable adults and their legal representative, are provided a copy of the service recipient rights to help them understand expectations of service delievery and how to exercise and protect their rights.

26. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clauses (8) and (9).

Violation: The license holder did not ensure protection related rights as required.

a. During a visit to the home of P15, a licensed community residential setting facility, MN Bridges Pearl Lake, license number 1090335, a DHS licensor observed missing and broken cupboard doors, missing and broken closet doors, a toilet with the seat broken off and sitting on the bathroom sink, and a stove with baking soda sprinkled on three of the four burners.

During an interview with P15, P15 stated that they are afraid to use the stove because three of the four burners catch on fire when in use. P15 showed the DHS licensor a box of baking soda next to the stove and stated that they keep it there to pour onto the burners when this happens. There was evidence of baking soda in the three burners that supported P15’s statement.

The license holder failed to ensure P15’s right to receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site.

b. During a visit to the home of P25, a licensed community residential setting facility, MN Sunrise, license number 1097762, a DHS licensor observed that the basement hallway leading to the housing area of P25. This hallway contained litter, had unfinished framing, and cracked concrete. Outside of the home, the concrete staircase to the front door was disintegrating with large pieces missing from the steps.

· Bridges MN Policy and Procedure on Universal Precautions and Sanitary Practices states, “A Residential Supervisor or Property Manager will ensure that the program site, including interior and exterior of buildings, structures, enclosures, walls, floors, ceilings, registers, fixtures, equipment, and furnishings are maintained in good repair and in sanitary and safe condition.

· Bridges MN failed to enforce their policies and procedures that promote health and welfare regarding Universal Precautions and Sanitary Practices.

c. During a visit of P43’s home, a licensed community residential setting, Bridges MN Magnolia, license number 1099274, it was discovered that P43’s home was littered with personal items, which could make it difficult for staff to ensure health and safety of P43. The basement contained large amounts of items in piles, including trash.

The protection related rights directly relate to the persons served health and safety. The license holder was owner, lessor or tenant of the residential service sites and had direct responsibility through the services provided in those homes to ensure the service sites were clean and safe environments that would not jeopardize the health and safety residing in the service sites. This license holder has repeatedly failed to ensure compliance as ordered within the Home and Community-Based Services Rules and Statute and orders by the Commissioner.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: June 14, 2019, December 31, 2019, May 20, 2021 and October 15, 2021.

SERVICE PLANNING AND REVIEW

27. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: For four of forty-three persons whose records were reviewed (P5, P6, P7, P11), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required.

e. The license holder failed to include an individualized assessment of P5, P6, and P11’s susceptibility of abuse.

· P5’s IAPP stated that P5 was not susceptible to self- abuse; however, this assessment was not consistent with information reviewed elsewhere in P5’s record. The coordinated services and supports plan (CSSP) completed by P5’s case manager stated that P5 was at risk of self-isolation and that P5 may need assistance to be more active in the community and to find activities to improve P5’s physical and mental health.

· P6’s IAPP stated that P6 is not susceptible to sexual abuse; however, this assessment was not consistent with information reviewed elsewhere in P6’s record. P6’s record had a document titled “Required Residential Rate Exception Request Form.” This document indicated that P6 has sexual predatory behavior. A DHS licensor asked the license holder about this and the license holder stated that there was an incident where P6 was masturbating in front of a neighbor’s window. This type of incident could make P6 susceptible to sexual abuse from others.

· P11’s CSSP addendum stated that P11 has a history of suicidal and homicidal ideations. However, P11’s IAPP does not specifically mention this, nor does it contain specific measures to minimize the risks associated with suicidal and homicidal ideations.

f. P7 received night supervision and individualized home supports with training services from the license holder. The license holder developed an IAPP for P7; however, the license holder failed to document the statement of measures that would be taken to minimize the risk of abuse within the scope of each service P7 was receiving.

An individual abuse prevention plan (IAPP) provides license holders and their staff with steps that must be taken to minimize the risk of abuse to that vulnerable adult when it has been assessed they are susceptible to: physical abuse, self-abuse, sexual abuse, and financial exploitation. When a vulnerable adult is assessed to be at risk for one, or all the areas of abuse, an individualized assessment must be completed and documented to show specific actions the program will take to minimize the risk of abuse within the scope of service. Bridges MN failed to ensure the health and safety of the persons served within the program was accurately documented in the record. This may jeopardize the health and safety of the persons served as staff implementing services would not have accurate information on how to mitigate the risk of abuse.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 22, 2018, June 14, 2019, December 6, 2021, and February 25, 2022.

28. Citation: Minnesota Statues, section 245D.06, subdivision 4, paragraph (a).

Violation: For four persons whose records were reviewed (P17, P18, P21 and P27), the license holder did not meet the requirements for safekeeping of funds and property as required.

a. Regarding P17, the license holder was responsible for safekeeping of funds. The license holder failed to maintain balanced financial ledgers. P17’s financial ledgers for April 2022 had discrepancies. Beginning and ending balances for were inaccurate, and deposits and withdrawals were missing or not documented accurately.

b. Regarding P18, the license holder was responsible for safekeeping of funds. The license holder failed to maintain balanced financial ledgers. P18’s financial ledgers for Jan-March 2022 had discrepancies. Beginning and ending balances for were inaccurate, and deposits and withdrawals were missing or not documented accurately.

c. Regarding P21, the license holder was responsible for safekeeping of funds. The license holder failed to maintain balanced financial ledgers. P21’s financial ledgers for Jan-April 2022 had discrepancies. SP21’s petty cash ledger was illegible which resulted in inaccurate documentation for deposits and withdrawals.

d. Regarding P27, the license holder failed to document the frequency of receiving statements from P27’s case manager. Additionally, the license holder was responsible for maintaining and providing receipts to P27’s legal representative. At the time of the review, the license holder was unable to provide information showing this was completed.

When the license holder has been assigned responsibility for assisting a vulnerable adult or child with the safekeeping of funds and property, the license holder is responsible for obtaining written authorization to do so, from the person, their legal representative, and their case manager. The written authorization documents the preferences of the team, on how frequently reports and receipts will be provided to the team members.

Repeat Violation: The license holder was cited for a similar violation in a correction order dated June 14, 2019.

29. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For five persons whose records were reviewed (P1-P4 and P12) the license holder did not provide services as assigned in the coordinated service and support plan and provisions of service that complied with the requirements of chapter 245D and federal waiver plans.

NOTE: According to the Community-Based Services Manual (CBSM), primary caregiver is defined for 24-hour emergency assistance as the individual principally responsible for the care and supervision of the person. S/he must maintain his/her primary residence at the same address as the person and be named as an owner or lessee of the primary residence.

g. The license holder failed to comply with the federal waiver plan while providing individualized home supports with training and 24 hour emergency assistance services to P1. P1 received both of these services from a live-in caregiver (SP22). Although P1 and SP22 have separate leases, they share the same address and SP22 meets the definition of primary caregiver as described above. The primary caregiver cannot be the person who delivers the 24 hour emergency assistance service.

h. The license holder failed to comply with the federal waiver plan while providing employment support services to P2, P3, and P4. P2, P3, and P4 work for a company called “The Crew.” Individuals who own and operate “The Crew” are also listed as controlling individuals for Bridges MN. In addition, the registered office address for “The Crew” is the same office address for the license holder.

The federally approved waiver plan prohibits the employment support services provider, Bridges MN, from providing employment support services to their own community business, “The Crew.” The federally approved waiver plan stated “employment support service providers cannot be involved as owners, partners, shareholders, operators, managing entities, employees or otherwise beneficiaries of a community business where they are providing employment support services.”

c. P12’s coordinated service and support plan stated that P12 was to receive 2:1 staffing for 14 hours per day and 1:1 staffing for 10 hours per day. P12 also received a rate exception to support the need for these staffing hours. However, there were numerous times between the dates of March 25, 2022, and April 24, 2022, that the license holder failed to provide P12 with the required staffing ratios as assigned in the coordinated service and support plan.

The Coordinated Service and Support Plan (CSSP) is completed when a person is eligible for and chooses to receive publically funded home and community- based services and/or state plan services. A CSSP addendum is the provider developed and maintained record that ensures that they provide the services and supports detailed in the CSSP and required by Minnesota statues and rules. Within this record the provider and the person’s team documents assessments, plans, outcomes, and objectives for services. This document is also is revised at specified intervals or as needed or requested. Bridges MN has a chronic, documented history of failing to provide services as documented in the CSSP addendum.

Bridges MN has been cited as indicated above, for failing to provide services as defined by federal waiver plans. Since 2019, Bridges MN has failed to comply with applicable Minnesota Statutes or Rules regarding who can provide services, where services are provided and how services are provided to vulnerable adults and children. Bridges MN has continued to provide services that do not meet the federal waiver guidelines and continues to provide services outside of the limitations approved by the federal government. The program is unable, or unwilling to comply to orders provided by the Commissioner.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019, August 28, 2019, March 10, 2020, March 12, 2020, May 20, 2021, December 6, 2021, and February 25, 2021.

30. Citation: Minnesota Statutes, section 245D.07, subdivision 2.

Violation: For two persons whose record was reviewed (P6 and P7), the license holder did not meet service planning requirements for basic support services as required.

a. The license holder provided specialist services to P6. P6’s specialist services were initiated on January 12, 2022.  The license holder failed to review and revise, as needed, P6’s preliminary coordinated service and support plan (CSSP) addendum within 60 days of service initiation. The license holder later reviewed P6’s preliminary CSSP addendum on March 17, 2022.

b. The license holder provided both individualized home supports with training and night supervision services to P7. P7’s CSSP addendum stated that P7 received individualized home supports with training and 24 hour emergency assistance services. Although the license holder held a meeting to review P7’s preliminary CSSP addendum within 60 days of service initiation, the license holder failed to review and revise, as needed, P7’s preliminary CSSP addendum for night supervision services.

31. Citation: Minnesota Statutes, section 245D.071, subdivision 3 paragraph (d).

Violation: For one person whose record was reviewed (P20), the license holder did meet the requirements for assessment and initial service planning, as required.

P20’s 45 day meeting was held on July 2, 2021. The license holder failed to determine how technology might be used to meet the person's desired outcomes, including summary of the discussion, any decisions, and any further research that may need to be completed before a decision can be made.

32. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraphs (g).

Violation: For six persons whose records were reviewed (P4, P11, P14, P17, P27 and P29), the license holder did not meet the requirements for progress reports as required.

a. The coordinated service and support plan addendum for P4 required semi-annual progress reports. Although the license holder provided semi-annual progress reports for P4, the license holder failed to make recommendations in P4’s Employment Support Services progress report dated February 15, 2022.

b. For P11 and P14, the license holder did not provide a rational for changing, continuing, or discontinuing the current outcomes and supports.

c. For P17’s progress review report dated January 24, 2022, the license holder failed to include recommendations and the rationale for changing, continuing, or discontinuing implementation of supports and methods in the progress review reports.

d. For P27, in a progress report and recommendation dated February 27, 2022, the license holder documented a rational for changing, discontinuing or modifying an outcome as, “P27 is unsure at this time if they would like to continue this goal or change it, -team support.”

e. For P29, in a progress report and recommendation dated July 1, 2021, the license holder documented a rational for changing, discontinuing or modifying an outcome as, “keeping this goal to re-evaluate at the annual meeting.”

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019, February 5, 2021, May 20, 2021, and November 9, 2021

POSITIVE SUPPORTS AND PERSON CENTERED PLANNING

33. Citation: Minnesota Rules, part 9544.0030, subpart 1.

Violation: For one persons whose records were reviewed (P31), the license holder did not evaluate positive support strategies as required.

The license holder failed to evaluate with P31 whether the persons identified positive support strategies met the standards in subpart 2, at least every six months. At the time of the review, P31’s record provided the following review dates:

· September 9, 2020;

· November 2, 2020;

· January 20, 2021; and

· September 29, 2021.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14, 2019 and May 20, 2021.

34. Citation: Minnesota Rules, part 9544.0060, subpart 2, item Q. 

Violation: For one person whose record was reviewed (P39), the license holder failed to ensure actions or procedures were prohibited from use as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience as required.

For P39’s incentive plan dated April 2022, the license holder implemented a level program that included a response cost or negative punishment component.

When P39 would not engage in a target behavior, s/he received an incentive. The incentive would increase in value depending on how many days in a row P39 was successful. However, if P39 were not successful, s/he would lose all the cumulative days earned and have to start back to day one.

35. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For seven persons whose records were reviewed (P7, P11, P12, P14, P25, P27 and P28), the license holder did not provide services in response the person’s identified needs, interests, preferences and desired outcomes as specified in the coordinated service and support plan (CSSP) and CSSP addendum as required.

a. The license holder provided both individualized home supports with training and night supervision services to P7. The license holder failed to ensure that P7’s CSSP addendum identified how services are provided for the night supervision service, including how, when, and by whom.

b. P11’s CSSP addendum dated October 2021 stated that P11’s chosen outcomes were to clean his/her room every week and to create a $20 weekly budget. It also stated that the previous outcome of cleaning the van would be discontinued. However, current data tracking sheets reflected that the current outcome being implemented was cleaning the van. Additionally, during an interview with a staff person on site at P11’s home, the staff person stated that P11 rarely completes this outcome because P11 “hates doing it.”

c. P12’s 45 day meeting was held on December 2, 2021. The CSSP addendum that was approved by the team at that meeting stated that the outcomes P12 chose were to save $5.00 per week for the future purchase of a cat and to host a social event at his/her house one time per week. However, the outcomes that were being implemented and documented on during January, February, March and April were to go to the gym and to take guitar lessons.

d. P14’s CSSP Addendum dated December 21, 2021, stated that P14’s outcomes would be changed from “exploring volunteer opportunities” to “volunteering at the humane society” to prepare P14 for owning a future pet. However, the current data tracking sheets for April 2022 reflect that the outcome being implemented was still “exploring volunteer opportunities.”

e. P15’s progress review report from March of 2022 provided a progress update for outcomes related to interpersonal skills, attending the YMCA, and keeping room clean. However, the data tracking sheets for the months prior to that progress review indicated that the outcomes being implemented and tracked were related to meal planning and preparation, interpersonal skills, and keeping TV at appropriate volume.

f. P25’s CSSP addendum dated April 7, 2021, stated that P25’s chosen outcome to engage in more sensory based community activities by participating in two community activities per month with a 75% success rate in a six month period review. However, current data tracking sheets in the home reflected that P25 had not met this goal since implementation on April 22, 2021. During a conversation with staff onsite on April 26, 2022, the staff indicated that P25 repeatedly refuses participation in this goal.

g. For P27, during a conversation that took place on April 27, 2022, with SP29, it was determined that P27’s goals that involved cooking and cleaning to maintain independence were requested to be implemented by P27’s guardian and not the person served.

h. A DHS licensor visited P16’s home on May 3, 2022. The licensor requested to review P16’s outcome and supports being implemented. At the time of the review, there were no outcome and supports documented, or outcome data tracking sheets on site. During an interview with staff onsite, they stated the “manager” had not brought May tracking sheets. Staff were unable to implement and/or document the outcomes in P16’s CSSP addendum.

Person centered planning and service delivery identifies how the license holder must provide the services, in response to the persons served identified:

· needs;

· interests;

· preferences; and

· desired outcomes as specified in the CSSP and CSSP Addendum

License holders must provide services in a manner that supports vulnerable adult and children’s preferences, daily needs and activities and accomplishment of the person’s goals and service outcomes. This citation demonstrates that Bridges MN has not met this requirement and continues to fail to provide services according to person-centered planning requirements. Bridges MN attended person centered training sponsored by DHS on July 14, 19, and 22, 2021 and participants included, according to the license holder, the program’s management, designated coordinators, and designated managers.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated December 29, 2017, June 14, 2019, August 19, 2020, and May 20, 2021.

SUPPORTS AND OUTCOMES

36. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b).

Violation: For four persons whose records were reviewed (P2, P3, P19, P28), the license holder did not meet the service planning requirements for an intensive service as required.

For P2, P3, P19, P28 the license holder failed to document the following supports and methods to be implemented to support the person and accomplish outcomes:

a. P2’s employment outcome stated, “[P2] will bring additional items, such as water on a hot day, as needed with [him/her] to the work site, with 1 or fewer verbal cues for 100% of applicable trials.” The outcome did not list the amount of trials or how often this outcome would be attempted.  The license holder failed to document the measurable and observable criteria for identifying when the desired outcome had been achieved.

b. P3’s employment service outcome stated, “[P3] would like to work on the paperwork side of reinstating [his/her] driver’s license. [P3] will work with [his/her] ESP to pursue this goal with 1 or fewer verbal prompts for 75% of recorded applicable trials.” The outcome did not list the amount of trials or how often this outcome would be attempted. The license holder failed to document the measurable and observable criteria for identifying when the desired outcome had been achieved.  

c. For P19’s outcome titled “Choosing to Have Good Days,” the license holder failed to include the measurable and observable criteria for identifying when the desired outcome had been achieved. Additionally, the license holder failed to collect data on P19’s outcomes from May through September 2021.

d. P28’s outcome stated, “[P28] and staff will work together to use items or test out new items that have white noise 2x/week to bring them calm and peace with success rate of 50%.” Staff were required to document “what is working well for [P28] and what is not having a positive effect on them.” According to the license holder, staff were to document what was working and what was not working for P28 in daily logs. No documentation was found at the time of the review. Additionally staff were required to document a (+) when P28 achieved the goal, (–) when P28 did not achieve the goal, and N/A when the goal was not applicable to the staff’s shift. Staff failed to document 29 days in the month of January 2022 and two days in February 2022.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: June 14, 2019, May 20, 2021, December 6, 2021, February 25, 2022

37. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (a).

Violation: For two persons whose records were reviewed (P11 and P12), the license holder did not meet the requirements for ongoing review and development of the service plan as required.

a. P11’s coordinated service and support plan addendum required semi-annual meetings with P11’s support team. The license holder failed to hold a support team meeting as required in April 2022.

b. P12’s coordinated service and support plan addendum required quarterly progress review reports. A progress review report from January 2022 stated, “[P12] has expressed to this writer that [s/he] no longer wants to get a cat. When asked why, [P12] indicated that [s/he] had only wanted to get a cat in order to please [his/her] [spouse]. [P12] has indicated that [s/he] is no longer willing to take care of the cat and would rather participate in another activity. As a result, it is recommended that this outcome be discontinued.”

During an interview with the license holder, the license holder stated that this was completely “made up and untrue” and that P12 did get a cat and never indicated that they did not want one.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: November 9, 2021.

HEALTH NEEDS

38. Citation: Minnesota Statutes, section 245D.05, subdivision 1.

Violation: For seven persons whose records were reviewed (P7, P12, P16, P27—P29, and P38), the license holder did not maintain documentation of how the person’s health needs would be met as required when the license holder was assigned responsibility in the CSSP and CSSP addendum.

a. P7 had several medical devices and equipment, including a chest belt to be used when P7 was transported in a vehicle, a shower chair, and a hospital bed. The license holder failed to include a description of the procedures the license holder would follow to use the above-mentioned medical devices and equipment safely and correctly.

b. P12 was prescribed Hydroxyzine HCL 25 mg to be given up to four times per day as needed (PRN). The license holder failed to include a description of the procedures the license holder would follow when administering Hydroxyzine 25mg to P12.

c. P16 was prescribed Baclofen 10 mg PRN for anxiety and Methocarbamol 500 mg PRN (reason undocumented). The license holder failed to include a description of the procedures the license holder would follow when administering these PRNs.

d. P27 was prescribed Lorazepam PRN. The license holder failed to include a description of the procedures the license holder would follow when administering Lorazapam to P27.

e. P28 was prescribed Propranolol and Lorazapam PRN and the license holder was responsible for medication administration for P28.

· In a medication administration record dated March, 2022, it stated, “Take 1 tablet by mouth twice daily; hold if HR [heart rate] is less than 55.” At the time of the review, the license holder failed to ensure P28’s heart rate was monitored.

· The license holder failed to include a description of the procedures staff would follow when administering Lorazapam to P28.

f. P29 was prescribed Olanzapine PRN. The license holder failed to include a description of the procedures the license holder would follow when administering Olanzapine to P27.

g. P38 was prescribed Hydroxyzine Pamoate 50 mg PRN for anxiety. The license holder failed to include a description of the procedures the license holder would follow when administering Olanzapine to P38.

NOTE: P38’s record was also reviewed by DHS during a previous licensing review, January 10—January 14, 2022. Bridges MN was ordered to immediately document how health needs would be met for P38 in a correction order dated February 25, 2022. Bridges MN failed to complete the corrective actions ordered by the commissioner and is unable or unwilling to correct this error.

When the license holder is responsible for overseeing health services and the health needs of the persons served there are requirements for record keeping, reporting procedures, and program oversight. When Bridges MN was assigned responsibility of overseeing health needs in the CSSP and CSSP Addendum, they were required to maintain person specific documentation on how the person’s health will be met, including a description of the procedures the license holder will follow to:

· provide medications as needed by the person;

· monitor health conditions;

· assist with or coordinate health service appointments; or

· use medical equipment, devices or adaptive aids safely and correctly.

This documentation ensures staff, who are typically unlicensed staff, provide accurate and person specific cares when the license holder has been assigned responsibility to oversee health needs. This is inherently connected to the health and safety of the persons within the program that require this assistance and oversight.

Bridges MN has a chronic nature of failing to come in to compliance and maintain requirements within the program. Bridges MN is unable or unwilling to follow corrective actions ordered by the Commissioner.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated September 13, 2018, June 14, 2019, December 10, 2019, December 27, 2019, February 5, 2021, February 25, 2021, and in an Order of Conditional license dated March 10, 2020

39. Citation: Minnesota Statutes, section 245D.05, subdivision 1a.

Violation: For one person whose record was reviewed (P1), the license holder did not document medication setup in the MAR as required.

The license holder provided medication administration to P1 in the evenings and medication set up for P1 in the mornings. The license holder setup P1’s morning medications for P1’s PCA staff from another agency to administer each morning.

During the course of the licensing review, on April 26, 2022, the license holder discovered that P1 had nine additional current medications that were not listed on the MAR. Three of these medications were scheduled morning medications, and three of the medications were PRN medications. The morning medications not documented on P1’s MAR were Adderall 30 mg, Strattera 60 mg, Vitamin D3 1,000 IU each morning and had the following PRN medications: Zofran ODT 4 mg, Senna 8.6 mg, and Ibuprofen 400 mg.

The license holder failed to document the following in the MAR for the above-mentioned medications when assigned the responsibility of medication setup:

· dates of setup;

· name of medication;

· quantity of dose;

· times to be administered;

· route of administration at time of setup; and,

· when the person will be away from home, to whom the medications were given.

40. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (a).

Violation: For one person whose record was reviewed (P1), the license holder did not document the administration of medication as required.

The license holder was responsible for medication administration for P1’s evening medications. During the course of the licensing review, on April 26, 2022, the license holder discovered that P1 had nine additional current medications that were not listed on the medication administration record (MAR). The license holder was responsible for medication setup for three medications which P1 took in the morning. The license holder was responsible for medication administration of the other six medications. The license holder was unable to determine how long P1 had been taking these medications, but stated that none of the medications were new and P1 had been taking the medications for some time.

The license holder failed to document the administration of the medication or the reason for not administering the medication in P1’s MAR for Benadryl 25 mg; Melatonin 5 mg; Linzess 145 mcg; and the following PRN medications: Zofran ODT 4 mg, Senna 8.6 mg, and Ibuprofen 400 mg.

41. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b). 

Violation: For nine persons whose records were reviewed (P1, P9, P11, P12, P22, P23, P25, P26, and P31 ), the license holder did not ensure persons served took medication as prescribed when assigned responsibility of medication administration.

a. P1 was prescribed Linzess 145 mcg to be administered once daily. In an incident report dated April 28, 2022, the license holder indicated that P1’s staff had administered the Linzess as needed (PRN) instead of daily as prescribed. This medication was not listed on P1’s medication administration record.

b. P9 was prescribed 30 ml of Milk of Magnesia to be given on the second day of no bowel movement. According to P9’s medication administration record, P9 was given Milk of Magnesia, on January 16, 2022 and then again on January 17, 2022. This did not follow the protocol written within the coordinated service and support plan addendum.

c. P11’s medication administration record for March 2022 stated that Neomycin was discontinued on March 3, 2022; however, the license holder continued to administer this medication until March 20, 2022.

d. P11’s medication administration record included that a prescription for Melatonin 5 mg was discontinued on August 31, 2021. It was also documented in the medication administration records for September through December 2021 as discontinued.

The medication administration record for January 2022 documented that Melatonin 5 mg was administered from January 1 through January 14 with an “x” drawn through the initials and the word “error” written in under each of those days that it was initially signed off as administered. For the days of January 15, 16, and 17, it is documented with an “x” each day, and from January 18 through the end of the month, it is documented as administered.

During an interview with the license holder, the license holder stated that they received an order to discontinue the Melatonin 5 mg and begin Melatonin 10 mg on December 28, 2021. The license holder stated that they never received an order to discontinue the Melatonin 5 mg on August 31, 2021 and that was a mistake. The license holder stated that due to lack of insurance coverage, the Melatonin 10 mg was not available and was not started until January 18, 2022.

Therefore, the license holder failed to ensure that P11 received his/her medications in the following ways:

· the license holder failed to administer Melatonin as prescribed from August 31 through December 28, 2021;

· the license holder initially documented from January 1 through January 14 that Melatonin had been administered to P11; however the medication had not been administered as it was not available at the house until January 18; the license holder later documented that this was an error;

· when the license holder did receive the Melatonin 10 mg on January 18, 2022, the license holder continued to sign off a medication that was transcribed on the MAR as Melatonin 5 mg, rather than the actual dose of Melatonin 10 mg.

e. For P12, the license holder failed to administer 9 doses of Divalproex between February 4 and February 7, 2022 due to the medication being “not available.” P12 was prescribed Divalproex for seizures. P12 had a seizure on February 6, 2022.

f. For P22, the medication administration record for January 2022 indicated a refusal of prescribed Nicotine 21 mg patch applied every 24 hours on January 2, 3, 4, 5, 17, 18, 21, 23, 24, 25, 26, 27 and 28. The medication or treatment error or refusal reports indicated that the prescriber was not notified. The case manager was notified for the January 4, 2022 refusal and not the other 12 refusals.

g. For P23, according to medication or treatment error or refusal reports dated April 13, 14, 15, 16 and 17, the license holder indicated that the prescribed Regabalin 150 mg daily for P23 was not given; however, the prescriber and case manager were not notified.

h. For P25, according to the medication administration record review for February 2022, there were 10 medication errors.

· Ziprasidone Cap 60 mg, February 12 and 27

· Melatonin 2 tabs daily February 12 and 27

· Valproic Acid February 22, 26 and 27

· Famotidine February 27

· Escitalopram 20 mg daily February 21

· Gavilax February 22

For P25, according to the the medication administration record review for March 2022, there were 13 medication errors.

· Ziprasidone Cap 60 mg, March 27, 2022

· Melatonin March 6, 11, and 27

· Valproic Acid March 5, 6, 12, and 13

· Famotidine March 10, 11, 12, 13 and 14.

i. P26 was prescribed a psychotropic medication, Clonazepam 1 mg tab two times daily. The medication administration record indicated “X” for March 6 through 14, 2022. Staff told a DHS licensor that the “X” meant P26 refused the medication. A DHS licensor reviewed 18 separate health progress notes in P26’s record. It was noted that P26 needed to meet with psychiatrist to renew the medication.

P26 was under commitment and his/her psychotropic medications were court ordered. A DHS licensor asked SP45 if the prescriber and case manager were informed of the 18 missed doses. SP45 was unable to provide an answer. On March 14, 2022, P26 had a behavioral incident which resulted in his/her arrest and the license holder issued a temporary service suspension.

j. For P31, according to a medication or treatment error or refusal report dated March 28, 2022, the license holder indicated that on March 26 and 27, 2022, Divalproex (Depakote) 2000 mg, Trazodone 100 mg, and Melatonin 3 mg were not administered because the medications were “not available.”

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: June 14,2019, October 7, 2020, February 5, 2021, April 2, 2021, May 20, 2021, November 9, 2021, and a conditional order dated March 10, 2020.

Medication administration means:

· checking the person’s medication record;

· preparing the medications as prescribed;

· administering the medicaitons or treatment to the person;

· documenting the administration of the medication or treatment, or the reason for not administering the medication or treatment; and

· reporting to the persons doctor or nurse, any concerns about side effects, effectiveness, or a pattern of a person refusing their medication or treatment as their health care professional has prescribed.

When a license holder is responsible for administering medication, they must implement medication procedures to ensure the person take medications and treatments as prescribed.

Since 2019, Bridges MN has has failed to ensure medications and treatments are administered as prescribed. They have also failed to follow reporting procedures when it is discovered that persons served have not taken medications as prescribed. The health and safety of the persons served is jeopardized by the program’s lack of oversight.

42. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). 

Violation: For one person whose record was reviewed (P1), the license holder did not ensure information was documented in the person’s medication administration record (MAR) as required.

According to P1’s coordinated service and support plan (CSSP) addendum, the license holder was assigned responsibility for medication administration in the evenings and medication setup in the mornings. The license holder discovered that there were nine medications not listed on P1’s MAR during the course of the licensing review on May 26, 2022. Three medications were scheduled morning medications. Three of these medications were scheduled medications administered by the license holder and three medications were as needed (PRN) medications.

The license holder failed to document the following information in P1’s MAR for these six medications:

· the information on the current prescription label or the prescriber's current written or electronically recorded order or prescription that includes the person's name, description of the medication or treatment to be provided, and the frequency and other information needed to safely and correctly administer the medication or treatment to ensure effectiveness;

· 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; and

· 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.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 14,2019 and May 20, 2021 and a conditional order dated March 10, 2020.

43. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For three person whose record was reviewed (P1, P9 and P7) the license holder did not ensure that responsibilities related to reviewing and reporting medications issues and treatment issues as required.

a. The license holder was assigned responsibility for medication administration for P1’s evening medications.

· The license holder discovered on April 26, 2022, that P1 had nine additional medications that had not been listed on the MAR. The license holder was responsible to administer six of these medications.

· At the time of the review, the license holder had no way of verifying that the medications were administered.

· The license holder indicated that Linzess 145 mcg had only been administered as needed (PRN). This medication was prescribed to be administrated daily.

· The license holder failed to report the medication errors to the case manager when discovered. The license holder did not report the errors to the case manager until April 28, 2022.

· The license hold failed to ensure the information maintained in P1’s MAR was correct.

b. The license holder was assigned responsibility for medication administration for P7. On February 26, 2022, the staff person did not give P7 one of his/her medications. The license holder failed to report the medication error to P7’s case manager.

c. The license holder was assigned responsibility for medication administration for P9. P9 was prescribed 30 ml of Milk of Magnesia to be given on the second day of no bowel movement. According to P9’s medication administration record, P9 was given Milk of Magnesia on January 16, 2022 and then again on January 17, 2022. The license holder failed to report the medication error to P5’s case manager.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated May 1, 2019, June 14,2019, December 27, 2019, February 2, 2021, May 20, 2021, December 6, 2021, and February 25, 2022 and a conditional order dated March 10, 2020.

44. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b).

Violation: For three persons whose records were reviewed (P1, P7 and P28), The license holder did not maintain conditions for psychotropic medication administration as required.

a. P1 was prescribed Trazadone 50 mg, Clonazepam 0.5 mg, Strattera 60 mg, Melatonin 5 mg, and Adderall 30 mg. The license holder failed to maintain documentation that included a description of the target symptoms that each psychotropic medication was to alleviate.

b. P7 was prescribed Guanficine 1 mg, Guanficine 1.5 mg, Pregablin 20 mg and Ariprprazole 20 mg. The license holder failed to maintain documentation that included a description of the target symptoms that each psychotropic medication was to alleviate.

c. P28 was prescribed Olanzapine 10 mg, Olanzapine 5 mg and Propranolol 20 mg. in a psychotropic medication use and monitoring form signed and dated October 25, 2021 by P28’s prescriber, the license holder was responsible for tracking and maintaining frequency, intensity and duration of target symptoms. The license holder tracked dates in January and February, but failed to maintain documentation for March 2022.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: May 1, 2019, June 14,2019, February 5, 2021, May 20, 2021, December 6, 2021, February 25, 2021 and a conditional order dated March 10, 2020

STAFFING STANDARDS

45. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For one staff person (SP9) whose record was reviewed, the license holder did not provide an orientation to the license holder's program abuse prevention plan within 72 hours of first providing direct contact services as required.

SP9’s date of hire was November 15, 2021. SP9 first began providing direct contact services on November 19, 2022. The license holder failed to provide an orientation to SP9 on the license holder’s program abuse prevention plan (PAPP) within 72 hours of SP9 first providing direct contact services.

SP9’s personnel file had a document titled “Hennepin Annual Meeting Paperwork Update” dated November 19, 2021. This form was used to document training that staff had on annual updates to the person’s served CSSPA. The license holder stated that SP9 completed this form instead of the form for staff orientation and familiarization to the worksite. The license holder stated that had completed all of the required orientation training; however, the form that SP9 completed did not have documentation showing that SP9 reviewed the PAPP. The license holder later provided SP9 with this training on January 4, 2022.

46. Citation: Minnesota Statutes, section 245D.081, subdivision 1, paragraph (a).

Violation: The license holder did not ensure the designated coordinators and the designated managers provided program coordination and evaluation as required.

a. The designated coordinators identified by the license holder failed to provide supervision, support, and evaluation of the activities that include:

· oversight of the license holder’s responsibilities as assigned in the person’s coordinated service support plan and the coordinated service support plan addendum;

· taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07;

· instruction and assistance to direct support staff implementing the coordinated service support plan and service outcomes, including direct observation of service delivery sufficient to assess staff competency; and

· evaluation of the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measureable and observable criteria for identifying when the desired outcome had been achieved according to the requirements in section 245D.07.

See citations in this section as evidence of the failures of the designated coordinators identified by the license holder.

b. The designated managers identified by the license holder failed to provide program management and oversight of the services provided by the license holder that include:

· maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (b);

· ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2;

· evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04;

· ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5;

· ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

See citations in this section as evidence of the failures of the designated managers.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: June 14, 2019, December 27, 2019, March 12, 2020, May 20, 2021, December 6, 2021, and a conditional order dated March 20, 2020.

47. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For 16 staff persons whose records were reviewed (SP23, SP26 and SP31-44), the license holder did not provide orientation to individual service recipient needs as required .

a. P7 had several medical devices and equipment documented in his/her coordinated service and support plan addendum, including a chest belt to be used when P7 was transported in a vehicle, a j-tube for medications to be administered through, a hoyer lift, bi-pap machine, a shower chair, and a hospital bed. SP23 and SP26 worked with P7.

· The license holder failed to provide an orientation to individual service recipient needs to SP23 and SP26. Both SP23 and SP26 completed a form titled “Hennepin Familiarization to the Worksite” form. SP23’s form was dated October 4, 2021 and SP26’s form was dated August 3, 2021.

· The form included a section titled “Orientation to Individual Service Recipient Needs.” In this section, it documented training provided to staff on required specialized care or medical equipment for P7.

· The area for specialized care and medical equipment stateed that the date of training, name of the medical equipment, and the name of the person who provided the training. The form instructs staff to write “NA” if not applicable.

· P26’s form lists their first name and date of October 1, 2021 in the area to indicate that they had been trained on specialized care and medical equipment.

· The license holder stated that SP26 had been trained on P7’s medical equipment and that the date listed was incorrect; however, a DHS licensor and the license holder, were unable to determine if, and when the training occurred, as the license holder did not document which medical equipment P26 was trained on.

· The training date listed, October 1, 2021, was after SP26 provided unsupervised direct contact services to P7. P26 began providing unsupervised direct contact services with P7 on August 3, 2021.

· SP23 was responsible for using specialized medical equipment as part of providing services to P7. On the familiarization form, the section was documented as “NA” (not applicable).

· Additionally, the form titled, “Orientation to Individual Service Recipient Needs” requires staff to list the person’s served, by their initials when signing off on specific training completed. Under the health needs section, SP23 and SP26’s form is documented as “NA.”

b. A DHS licensor requested specific onsite familiarization staff training in regards to P25 for SP31—SP44. P25 has a history of consistent aggression and self-harm by throwing self on the ground. S/he requires 1:1 supervision and awake overnight staffing. The license holder failed to provide orientation to the individual service recipient needs to SP31—SP44.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated: March 22, 2019, June 14, 2019, December 4, 2019 and May 20, 2021.

INCIDENT REPORTING AND PROCEDURE

48. Citation: Minnesota Statutes, section 245D.06, subdivision 1.

Violation: For four persons whose records were reviewed (P24, P34, P41 and P42) the license holder did not report serious injuries as required.

a. For P24, the license holder failed to report a serious injury within 24 hours as required. For a serious injury that took place April 22, 2022, the license holder reported it to the Department of Human Services (DHS) on April 25, 2022.

b. For P34, the license holder failed to report a serious injury within 24 hours as required.

· For a serious injury that took place May 23, 2022, the license holder reported it to the Department of Human Services (DHS) on May 26, 2022;

· For a serious injury that took place May 19, 2022, the license holder reported it to the Department of Human Services (DHS) on May 26, 2022;

· For a serious injury that took place May 17, 2022, the license holder reported it to the Department of Human Services (DHS) on May 25, 2022; and

· For a serious injury that took place May 13, 2022, the license holder reported it to the Department of Human Services (DHS) on May 25, 2022.

c. For P35, the license holder failed to report a serious injury within 24 hours as required. For a serious injury that took place May 28, 2022, the license holder reported it to the Department of Human Services (DHS) on May 31, 2022.

d. For P42, the license holder failed to report a serious injury within 24 hours as required. For a serious injury that took place May 3, 2022, the license holder reported it to the Department of Human Services (DHS) on May 11, 2022.

e. For P41, the license holder failed to report a serious injury within 24 hours as required. For a serious injury that took place April 22, 2022, the license holder reported it to the Department of Human Services (DHS) on April 25, 2022.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated August, 14, 2020, December 31, 2020, and November 9, 2021.

V. YOUR RIGHT TO APPEAL

You have right to appeal the maltreatment determination and/or revocation. Please see options below.

Should you exercise your rights to appeal send:

1.

Right to appeal the Revocation Order and maltreatment determination

You have the right to appeal the Revocation and maltreatment determination. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 15 calendar days from when you received this order. See address Section V.

If your request is being personally delivered, it must be received by DHS within 15 calendar days from when you received this order. See address in Section V.

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order.

2. Request for reconsideration of the maltreatment determination only

If you do not appeal the Revocation, you may still request reconsideration of the maltreatment determination. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to request reconsideration began when you received this order.

Your request must:

· Be in writing

· Clearly state that you are requesting reconsideration of the maltreatment determination

· Identify what is inaccurate or incomplete about the information in the Investigation Memorandum

· Supply information that is accurate or more complete

· State why you believe the finding of maltreatment should be changed

· Be made before the deadlines provided below.

Your request must be postmarked within 15 calendar days from when you received this order. See address in Section V.

A response to your reconsideration request will be mailed within 15 working days after DHS receives your request. You have the right to request a fair hearing if a response is not mailed within 15 working days.

3. Right to appeal the Revocation Order only

You have the right to only appeal the Revocation Order. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. See address in Section V.

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. See address in Section V.

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order.

4. Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.justice4mn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Operating the program pending the outcome of the appeal:

If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license.

· The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b).

· “Controlling individual” is defined under Minnesota Statutes, section 245A.02, subdivision 5a.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

· If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b).

· License holders must have and enforce written policies and procedures related to suspected maltreatment, under 245A.65, subdivision 1.

Questions

If you have any further questions regarding the determination of maltreatment you may contact Melanie Daniel, Investigations Supervisor, at 651-431-6559. If you have questions about the license revocation you may contact Christala Culhane, HCBS Supervisor, at 651-431-6541.

Sincerely,

Alyssa Dotson

Deputy Inspector General

Office of Inspector General, Licensing Division

Enclosure

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/