245D.10 POLICIES AND PROCEDURES.
A license holder providing either basic or intensive supports and services must establish, enforce, and maintain policies and procedures as required in this chapter, chapter 245A, and other applicable state and federal laws and regulations governing the provision of home and community-based services licensed according to this chapter. A license holder must use forms provided by the commissioner to report service suspensions and service terminations under subdivisions 3 and 3a.
The license holder must establish policies and procedures that promote service recipient rights by providing a simple complaint process for persons served by the program and their authorized representatives to bring a grievance that:
(1) provides staff assistance with the complaint process when requested, and the addresses and telephone numbers of outside agencies to assist the person;
(2) allows the person to bring the complaint to the highest level of authority in the program if the grievance cannot be resolved by other staff members, and that provides the name, address, and telephone number of that person;
(3) requires the license holder to promptly respond to all complaints affecting a person's health and welfare. For all other complaints, the license holder must provide an initial response within 14 calendar days of receipt of the complaint. All complaints must be resolved within 30 calendar days of receipt or the license holder must document the reason for the delay and a plan for resolution;
(4) requires a complaint review that includes an evaluation of whether:
(i) related policies and procedures were followed and adequate;
(ii) there is a need for additional staff training;
(iii) the complaint is similar to past complaints with the persons, staff, or services involved; and
(iv) there is a need for corrective action by the license holder to protect the health and welfare of persons receiving services;
(5) based on the review in clause (4), requires the license holder to develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the license holder, if any;
(6) provides a written summary of the complaint and a notice of the complaint resolution to the person and case manager that:
(i) identifies the nature of the complaint and the date it was received;
(ii) includes the results of the complaint review;
(iii) identifies the complaint resolution, including any corrective action; and
(7) requires that the complaint summary and resolution notice be maintained in the service recipient record.
(a) The license holder must establish policies and procedures for temporary service suspension that promote continuity of care and service coordination with the person and the case manager and with other licensed caregivers, if any, who also provide support to the person. The policy must include the requirements specified in paragraphs (b) to (f).
(b) The license holder must limit temporary service suspension to situations in which:
(1) the person's conduct poses an imminent risk of physical harm to self or others and either positive support strategies have been implemented to resolve the issues leading to the temporary service suspension but have not been effective and additional positive support strategies would not achieve and maintain safety, or less restrictive measures would not resolve the issues leading to the suspension;
(2) the person has emergent medical issues that exceed the license holder's ability to meet the person's needs; or
(3) the program has not been paid for services.
(c) Prior to giving notice of temporary service suspension, the license holder must document actions taken to minimize or eliminate the need for service suspension. Action taken by the license holder must include, at a minimum:
(1) consultation with the person's support team or expanded support team to identify and resolve issues leading to issuance of the notice; and
(2) a request to the case manager for intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support the person in the program. This requirement does not apply to temporary suspensions issued under paragraph (b), clause (3).
If, based on the best interests of the person, the circumstances at the time of the notice were such that the license holder was unable to take the action specified in clauses (1) and (2), the license holder must document the specific circumstances and the reason for being unable to do so.
(d) The notice of temporary service suspension must meet the following requirements:
(1) the license holder must notify the person or the person's legal representative and case manager in writing of the intended temporary service suspension. If the temporary service suspension is from residential supports and services as defined in section 245D.03, subdivision 1, paragraph (c), clause (3), the license holder must also notify the commissioner in writing;
(2) notice of temporary service suspension must be given on the first day of the service suspension; and
(3) the notice must include the reason for the action, a summary of actions taken to minimize or eliminate the need for temporary service suspension as required under this paragraph, and why these measures failed to prevent the suspension.
(e) During the temporary suspension period, the license holder must:
(1) provide information requested by the person or case manager;
(2) work with the support team or expanded support team to develop reasonable alternatives to protect the person and others and to support continuity of care; and
(3) maintain information about the service suspension, including the written notice of temporary service suspension, in the service recipient record.
(f) If, based on a review by the person's support team or expanded support team, that team determines the person no longer poses an imminent risk of physical harm to self or others, the person has a right to return to receiving services. If, at the time of the service suspension or at any time during the suspension, the person is receiving treatment related to the conduct that resulted in the service suspension, the support team or expanded support team must consider the recommendation of the licensed health professional, mental health professional, or other licensed professional involved in the person's care or treatment when determining whether the person no longer poses an imminent risk of physical harm to self or others and can return to the program. If the support team or expanded support team makes a determination that is contrary to the recommendation of a licensed professional treating the person, the license holder must document the specific reasons why a contrary decision was made.
(a) The license holder must establish policies and procedures for service termination that promote continuity of care and service coordination with the person and the case manager and with other licensed caregivers, if any, who also provide support to the person. The policy must include the requirements specified in paragraphs (b) to (f).
(b) The license holder must permit each person to remain in the program or to continue receiving services and must not terminate services unless:
(1) the termination is necessary for the person's welfare and the license holder cannot meet the person's needs;
(2) the safety of the person, others in the program, or staff is endangered and positive support strategies were attempted and have not achieved and effectively maintained safety for the person or others;
(3) the health of the person, others in the program, or staff would otherwise be endangered;
(4) the license holder has not been paid for services;
(5) the program or license holder ceases to operate;
(6) the person has been terminated by the lead agency from waiver eligibility; or
(7) for state-operated community-based services, the person no longer demonstrates complex behavioral needs that cannot be met by private community-based providers identified in section 252.50, subdivision 5, paragraph (a), clause (1).
(c) Prior to giving notice of service termination, the license holder must document actions taken to minimize or eliminate the need for termination. Action taken by the license holder must include, at a minimum:
(1) consultation with the person's support team or expanded support team to identify and resolve issues leading to issuance of the termination notice;
(2) a request to the case manager for intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support the person in the program. This requirement does not apply to notices of service termination issued under paragraph (b), clauses (4) and (7); and
(3) for state-operated community-based services terminating services under paragraph (b), clause (7), the state-operated community-based services must engage in consultation with the person's support team or expanded support team to:
(i) identify that the person no longer demonstrates complex behavioral needs that cannot be met by private community-based providers identified in section 252.50, subdivision 5, paragraph (a), clause (1);
(ii) provide notice of intent to issue a termination of services to the lead agency when a finding has been made that a person no longer demonstrates complex behavioral needs that cannot be met by private community-based providers identified in section 252.50, subdivision 5, paragraph (a), clause (1);
(iii) assist the lead agency and case manager in developing a person-centered transition plan to a private community-based provider to ensure continuity of care; and
(iv) coordinate with the lead agency to ensure the private community-based service provider is able to meet the person's needs and criteria established in a person's person-centered transition plan.
If, based on the best interests of the person, the circumstances at the time of the notice were such that the license holder was unable to take the action specified in clauses (1) and (2), the license holder must document the specific circumstances and the reason for being unable to do so.
(d) The notice of service termination must meet the following requirements:
(1) the license holder must notify the person or the person's legal representative and the case manager in writing of the intended service termination. If the service termination is from residential supports and services as defined in section 245D.03, subdivision 1, paragraph (c), clause (3), the license holder must also notify the commissioner in writing; and
(2) the notice must include:
(i) the reason for the action;
(ii) except for a service termination under paragraph (b), clause (5), a summary of actions taken to minimize or eliminate the need for service termination or temporary service suspension as required under paragraph (c), and why these measures failed to prevent the termination or suspension;
(iii) the person's right to appeal the termination of services under section 256.045, subdivision 3, paragraph (a); and
(iv) the person's right to seek a temporary order staying the termination of services according to the procedures in section 256.045, subdivision 4a or 6, paragraph (c).
(e) Notice of the proposed termination of service, including those situations that began with a temporary service suspension, must be given at least 90 days prior to termination of services under paragraph (b), clause (7), 60 days prior to termination when a license holder is providing intensive supports and services identified in section 245D.03, subdivision 1, paragraph (c), and 30 days prior to termination for all other services licensed under this chapter. This notice may be given in conjunction with a notice of temporary service suspension under subdivision 3.
(f) During the service termination notice period, the license holder must:
(1) work with the support team or expanded support team to develop reasonable alternatives to protect the person and others and to support continuity of care;
(2) provide information requested by the person or case manager; and
(3) maintain information about the service termination, including the written notice of intended service termination, in the service recipient record.
(g) For notices issued under paragraph (b), clause (7), the lead agency shall provide notice to the commissioner and the Direct Care and Treatment executive board at least 30 days before the conclusion of the 90-day termination period, if an appropriate alternative provider cannot be secured. Upon receipt of this notice, the commissioner and the executive board shall reassess whether a private community-based service can meet the person's needs. If the commissioner determines that a private provider can meet the person's needs, the executive board shall, if necessary, extend notice of service termination until placement can be made. If the commissioner determines that a private provider cannot meet the person's needs, the executive board shall rescind the notice of service termination and re-engage with the lead agency in service planning for the person.
(h) For state-operated community-based services, the license holder shall prioritize the capacity created within the existing service site by the termination of services under paragraph (b), clause (7), to serve persons described in section 252.50, subdivision 5, paragraph (a), clause (1).
(a) The license holder must review and update, as needed, the written policies and procedures required under this chapter.
(b)(1) The license holder must inform the person and case manager of the policies and procedures affecting a person's rights under section 245D.04, and provide copies of those policies and procedures, within five working days of service initiation.
(2) If a license holder only provides basic services and supports, this includes the:
(i) grievance policy and procedure required under subdivision 2; and
(ii) service suspension and termination policy and procedure required under subdivision 3.
(3) For all other license holders this includes the:
(i) policies and procedures in clause (2);
(ii) emergency use of manual restraints policy and procedure required under section 245D.061, subdivision 9, or successor provisions; and
(iii) data privacy requirements under section 245D.11, subdivision 3.
(c) The license holder must provide a written notice to all persons or their legal representatives and case managers at least 30 days before implementing any procedural revisions to policies affecting a person's service-related or protection-related rights under section 245D.04 and maltreatment reporting policies and procedures. The notice must explain the revision that was made and include a copy of the revised policy and procedure. The license holder must document the reasonable cause for not providing the notice at least 30 days before implementing the revisions.
(d) Before implementing revisions to required policies and procedures, the license holder must inform all employees of the revisions and provide training on implementation of the revised policies and procedures.
(e) The license holder must annually notify all persons, or their legal representatives, and case managers of any procedural revisions to policies required under this chapter, other than those in paragraph (c). Upon request, the license holder must provide the person, or the person's legal representative, and case manager with copies of the revised policies and procedures.