July 13, 2015
Cindy Olson, Authorized Agent
202 3rd avenue south east
Barnesville, MN 56514
License Number: 1069380 - Home and Community-Based Services (HCBS)
LICENSING REVIEW REPORT
Dear Ms. Olson:
On June 24, 2015 an initial compliance monitoring visit was conducted at Doris Catherine
Brundage, located at 202 3rd avenue south east, Barnesville, Minnesota to determine compliance
with state and federal laws and rules governing the provision of home and community-based
services (HCBS) to persons with disabilities and age 65 and older under Minnesota Statutes,
Chapter 245D. The purpose of this visit was to provide technical assistance on how to achieve
and maintain compliance with the applicable laws and rules that govern the provision of home
and community-based services licensed under Minnesota Statutes, Chapter 245D.
During the visit it was determined that your program failed to achieve compliance with
applicable laws or rules; however, this failure did not imminently endanger the health, safety, or
rights of the persons served by your program. Therefore, the Commissioner is issuing this license
review report with corrective action needed and recommendations for achieving and maintaining
compliance with the applicable laws or rules.
Corrective Action Required and Recommendations for Achieving Compliance
Required compliance: Minnesota Statutes, section 245D.09; as related to staff training standards.
For two of two staff persons whose records were reviewed (SP1 and SP2), the
license holder failed to provide annual staff training in the following topics:
data privacy;
service recipient rights and staff responsibilities related to ensuring the exercise and
protection of those rights;
maltreatment reporting and service planning for vulnerable adults, and staff
responsibilities related to protecting persons from maltreatment and reporting
maltreatment;
safe and correct use of manual restraint on an emergency basis;
PO Box 64242 * Saint Paul, Minnesota * 55164-0242 * An Equal Opportunity Employer
http://www.dhs.state.mn.us/licensing
Cindy Olson
July 13, 2015
Page 2
staff responsibilities related to prohibited procedures; and
basic first aid training.
Corrective action to achieve and maintain compliance: Within 30 days of receiving this
report, and on a continuing basis, you must ensure that staff training standards are met as
required under this subdivision. It is recommended that you review the sample form
titled, “Staff Orientation and Training Packet” which was provided to you at the initial
compliance monitoring visit.
You must also ensure all direct service staff receive training on the following topics
annually:
data privacy;
service recipient rights and staff responsibilities related to ensuring the
exercise and protection of those rights;
maltreatment reporting and service planning for vulnerable adults, and
staff responsibilities related to protecting persons from maltreatment and
reporting maltreatment;
principals of person-centered service planning and delivery;
safe and correct use of manual restraint on an emergency basis;
staff responsibilities related to prohibited procedures;
basic first aid; and
other topics as determined necessary in the person’s coordinated service
and support plan by the case manager or other areas identified by the
license holder.
Required compliance: Minnesota Statutes, section 245D.081, subdivision 2, paragraph (b); as related to
designating a coordinating staff person or persons to provide program coordination and
evaluation or the services provided.
The designated coordinator identified by the license holder, SP1, did not meet the
minimum education and/or work experience qualifications:
a baccalaureate degree in a field related to human services, and one year of full-time
work experience providing direct care services to persons with disabilities or persons age
65 and older;
as associate degree in a field related to human services, and two years of full-time work
experience providing direct care services to persons with disabilities or persons age 65
and older;
a diploma in the field related to human services form an accredited post-secondary
institution and three years of full-time work experience providing direct care service to
persons with disabilities or persons age 65 and older; or
a minimum of 50 hours of education and training related to human services and
disabilities; and
Cindy Olson
July 13, 2015
Page 3
four years of full time work experience providing direct care service to persons with
disabilities or persons age 65 and older under the supervision of a staff person who meets
the qualifications identified in clauses (1) to (3).
Corrective action to achieve and maintain compliance: Within 30 days of receiving this
report, and on a continuing basis, you must designate a person who meets the competency
to provide program coordination and evaluation of your services. You were provide with
additional information regarding this requirement at the time of the initial compliance
monitoring visit.
Within 30 days of receipt of this report, you must submit the name of the person you
have ensured is competent to perform the required duties of the designated
coordinator. You must have verified and documented this person’s competence,
including the education and work qualifications noted above.
Required compliance: Minnesota Statutes, section 245D.081, subdivision 3, paragraph (b); as related to
designating a managerial staff person or persons to provide program management and oversight
of the services provided.
The designated manager identified by the license holder, SP1, did not meet the
minimum education and/or work experience qualifications:
minimally meets the education and training requirements identified in 245D.081,
subdivision 2, paragraph (b); and
have a minimum of three years of supervisory level experience in a program directing
direct support services to persons with disabilities of persons age 65 and older.
Corrective action to achieve and maintain compliance: Within 30 days of receiving this
report, and on a continuing basis, you must designate a person who meets the competency
to provide program management and oversight of your services. You were provided with
additional information regarding this requirement at the time of the initial compliance
monitoring visit.
Within 30 days of receipt of this report, you must submit the name of the person you
have ensured is competent to perform the required duties of the designated
manager. You must have verified and documented this person’s competence,
including the education and work qualifications noted above.
Required compliance: Minnesota Statutes, sections 245D.10 and 245D.11; as related to the
establishment, enforcement and maintenance of policies and procedures.
The license holder failed to establish policies and procedures on the following
topics as required:
safe medication assistance and administration,
Cindy Olson
July 13, 2015
Page 4
the license holder stated the “Safe Medication Assistance and
Administration Policy” dated 10/23/2013 was not written in
consultation with a registered nurse, nurse practitioner, physician
assistant, or medical doctor.
emergency response, reporting, and review.
Corrective action to achieve and maintain compliance: Within 30 days of receiving this
report, and on a continuing basis, you must ensure that policy and procedure standards
are met as required under this subdivision. You must revise your policies and procedures
as required under this subdivision. Sample policies and procedures were provided to you
at the initial compliance monitoring visit.
Required compliance: Minnesota Statutes, section 245D.095; as related to record keeping requirements.
The license holder failed to maintain required records and documentation
regarding service recipient, personnel orientation and training, and program
records.
Corrective action to achieve and maintain compliance: Within 30 days of receiving this
report, and on a continuing basis, you must ensure that record keeping standards are met
as required under this subdivision.
You must maintain the following information for each person receiving services:
service information, including service initiation information, verification
of the person’s eligibility for services, documentation verifying that
service have been provided as identified in the coordinated service and
support plan (CSSP) or CSSP addendum;
health information, including:
medical history;
special dietary needs;
allergies; and
when the license holder is assigned responsibility for meeting the
person’s health service needs according to section 245D.05:
current order for medication, treatments or medical
equipment;
a signed statement authorizing the license holder to act in a
medical emergency when the person’s legal representative,
if any, cannot be reached or is delayed in arriving;
medication administration procedures;
a medication administration record documenting the
implementation of the medication administration
procedures and the medication administration record
Cindy Olson
July 13, 2015
Page 5
reviews, according to the requirements in section 245D.05;
and
medical appointment schedule when the license holder is
assigned responsibility for assisting with medical
appointments;
the person’s current coordinated service and support plan or that
portion of the plan assigned to the license holder;
copies of the individual abuse prevention plan and assessments as
required under section 245D.071, subdivisions 2 and 3 and;
documentation of orientation to service recipient rights according to
section 245D.04, subdivision 1, and maltreatment reporting
policies and procedures according to section 245A.65, subdivision
1, paragraph (c).
You must maintain a personnel record of each employee to document and verify
staff qualifications, orientation, and training. The personnel records must include:
the employee’s date of hire;
completed application;
an acknowledgement signed by the employee that job duties were
reviewed with the employee and the employee understands those duties;
and
documentation that the employee meets the position requirements as
determined by the license holder;
documentation of staff qualifications, orientation, training and
performance evaluations as required under section 245D.09, subdivisions
3 to 5, including:
the date the training was completed;
the number of hours per subject area; and
the name of the trainer or instructor; and
a completed background study as required under chapter 245C.
You must also maintain compliance with the following service initiation and
service planning requirements, including record keeping and documentation,
which must be met no later than at the next annual meeting of the person’s
support team:
providing a written notice that identifies the person’s rights and an explanation of those
rights as required under section 245D.04, subdivision 1;
service planning for intensive support services as required under section 245D.071,
subdivision 3 and 4;
written authorization to assist the person with the safekeeping of funds or other property
according to section 245A.04, subdivision 13;
Cindy Olson
July 13, 2015
Page 6
orientation to the license holder’s internal and external reporting of maltreatment of
vulnerable adults policy and procedures as required under section 245A.65, subdivision
1, paragraph (c); and
orientation to the license holder’s program abuse prevention plan as required under
section 245A.65, subdivision 2, paragraph (a).
Submissions required as part of this report must be sent to your licensor at:
Commissioner, Department of Human Services
ATTN: Nichole Dawson
Licensing Division
PO Box 64242
St. Paul, MN 55164-0242
During the initial compliance monitoring visit, you were provided the following HCBS
resources, forms, policies, and/or support:
how to navigate and locate sample policies and forms on the HCBS website;
the 245D Help Desk contact information for assistance related to licensing standards;
copies of applicable sample policies and forms;
training resources from the College of Direct Support; and
contact information for your licensor.
The HCBS Unit of DHS Licensing Division has developed a number of tools to assist license
holders in achieving and maintaining compliance with HCBS standards. Please visit the DHS
website at www.mn.gov/dhs. Follow the Licensing link under General Public to access the
resources for HCBS licensed programs. These resources include sample policies, sample forms,
frequently asked questions, and self-monitoring checklists.
If you have any questions regarding this Licensing Review Report, please contact me.
Nichole Dawson, Human Services Licensor
Office of Inspector General
Licensing Division
651-431-6646