STATE LIENSING OMPLIANE REPORT Report #: HL21006020 Date oncluded: November 16, 2018 Date of Visit: November 6 and 7, 2018 Name, Address, and ounty of Facility Investigated: happy s Golden Shores 540 Park Avenue Hill ity, MN 55748 Aitkin ounty Name, Address, and ounty of Housing with Services Registration: happy s Golden Shores 540 Park Avenue Hill ity, MN 55748 Aitkin ounty Facility Type: Home are Provider Investigator s Name: Darin Hatch, Special Investigator Senior A visit was conducted to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, hapter 144 and 144A. The purpose of this visit was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, hapter 626 was alleged. To view a copy of the correction orders, if any, please visit http://www.health.state.mn.us/divs/fpc/directory/surveyapp/provcompselect.cfm, or call 651 201 4890 to be provided a copy via mail or email. If you are viewing this report on the MDH website, please see the attached state form.
STATEMENT OF DEFIIENIES AND PLAN OF ORRETION (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: OF PROVER HAPPY'S (X2) MULTIPLE ONSTRUTION HILL ITY, MN 55748 SUMMARY STATEMENTOF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) 0 000 Initial omments OMPLETE 0 000 ******ATTENTION****** is documenting the State Licensing orrection Orders using federal software. Tag numbers have been assigned to Minnesota State Statutes for Home are Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the surveyors' findings is the Time Period for orrection. Please disregard the heading of the fourth column which states "Provider's Plan of orrection." This applies to federal deficiencies only. This will appear on each page. There is no requirement to submit a plan of correction for violations of Minnesota state statutes. However, home care providers are required to document any action taken to comply with these correction orders, per Minn. Stat. 144A.474, Subd. 8(c). The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to Minn. Stat. 144A.474 Subd. 11 (b). HOME ARE PROVER LIENSING ORRETION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.482, these correction orders are issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL OMMENTS: On November 6 and 7, 2018, a complaint investigation was initiated to investigate complaint #HL21006020, HL21006021, HL21006022, HL21006023, HL21006024, and HL21006025. The following immediate correction orders are issued. 144A.476, Subd. 2 Employees, ontractors, and SS=I Volunteers PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS REFERENED TO THE APPROPRIATE DEFIIENY) Subd. 2. Employees, contractors, and volunteers. (a) Employees, contractors, and volunteers of a LABORATORY DIRETOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 5
STATEMENT OF DEFIIENIES AND PLAN OF ORRETION (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: OF PROVER HAPPY'S (X2) MULTIPLE ONSTRUTION HILL ITY, MN 55748 SUMMARY STATEMENTOF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) ontinued From page 1 PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETE home care provider are subject to the background study required by section 144.057, and may be disqualified under chapter 245. Nothing in this section shall be construed to prohibit a home care provider from requiring self disclosure of criminal conviction information. (b) Termination of an employee in good faith reliance on information or records obtained under paragraph (a) or subdivision 1, regarding a confirmed conviction does not subject the home care provider to civil liability or liability for unemployment benefits. This MN Requirement is not met as evidenced by: Based on document review and interview, the licensee failed to ensure background studies for employees were conducted as required by this statute and MN Statute 144.057. Moreover, the licensee failed to ensure employees who did not have a cleared background study were used under direct supervision as defined in MN Statute 245.02 Subd.8. Seven employees were to found to have been working in violation, three of which were disqualified due to criminal offenses, including one employee who was a predatory offender. This practice resulted in a level three violation (a violation that harmed a client's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death) and was issued at a widespread scope (when problems If continuation sheet 2 of 5
STATEMENT OF DEFIIENIES AND PLAN OF ORRETION (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: OF PROVER HAPPY'S (X2) MULTIPLE ONSTRUTION HILL ITY, MN 55748 SUMMARY STATEMENTOF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) ontinued From page 2 PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETE are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the clients). The findings include: Document review of background study results of the Department of Human Services (DHS) database revealed employees A,B,,D,E,F,G, did not have cleared background study results. Document review of employee files indicated the following: Employee A had a hire date of 3 15 18. A letter of a cleared background study result was not Employee B had a hire date of 6 6 18. A letter of a cleared background study result was not Employee had a hire date of 7 25 15. A letter of a cleared background study result was not Employee D had a hire date of 10 10 18. A letter of a cleared background study result was not Employee E had a hire date of 3 9 17. Employee E was employed until 7 25 18. A letter of a cleared background study result was not A letter from the DHS background study unit dated July 25, 2018 indicated Employee E was disqualified and must be removed from providing direct contact. Document review of a MAAR report from police indicated Employee E was not current on their If continuation sheet 3 of 5
STATEMENT OF DEFIIENIES AND PLAN OF ORRETION (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: OF PROVER HAPPY'S (X2) MULTIPLE ONSTRUTION HILL ITY, MN 55748 SUMMARY STATEMENTOF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) ontinued From page 3 PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETE predatory offender registration with the Bureau of riminal Apprehension. Police investigated by going to the licensee and speaking with the owner who confirmed Employee E was indeed a former employee with the licensee. Employee F had a hire date of 5 28 18. A review of DHS background study records indicated Employee F was disqualified and should not have been employed. A letter of a cleared back ground study result was not produced when requested. Document review of a MAAR report from police dated August 20, 2018 indicated police conducted a traffic stop and arrested Employee F. Employee F told police they were an employee of the licensee. Police indicated based on Employee F's criminal background, Employee F should not be working for the licensee. Employee G had a hire date of 5 28 18. A review of DHS background study records indicated Employee G was disqualified and should not have been employed. A letter of a cleared back ground study result was not produced when requested. Document review of a MAAR report from police dated August 20, 2018 indicated police conducted a traffic stop and arrested Employee G. Employee G told police they were an employee of the licensee. Police indicated based on Employee G's criminal background, Employee G should not be working for the licensee. During interview on November 6, 2018 at 2:33 p.m. owner (O) H said she thought she could use employees right away as long as she submitted a background study request to DHS. She said she did not realize she must wait for the results. O H If continuation sheet 4 of 5
STATEMENT OF DEFIIENIES AND PLAN OF ORRETION (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X2) MULTIPLE ONSTRUTION HAPPY'S OF PROVER SUMMARY STATEMENT OF DEFIIENIES (EAH DEFIIENY MUST BE PREEDED BY FULL REGULATORY OR LS ENTIFYING INFORMATION) HILL ITY, MN 55748 PROVER'S PLAN OF ORRETION (EAH ORRETIVE ATION SHOULD BE ROSS REFERENED TO THE APPROPRIATE DEFIIENY) OMPLETE ontinued From page 4 said she thought the registry results were the cleared results. After the process was explained, O H stated she used employees in violation of the requirements. O H said she will provide direct supervision or remove employees until she receives cleared results for all employees going forward. O H contacted DHS by phone to start the process to make the corrections. TIME PERIOD TO ORRET: IMMEDIATELY If continuation sheet 5 of 5