Rivers of Life.

correction orders issued pursuant to the last survey, completed on December 11, 2024, found not corrected at the time of the March 27, 2025, follow-up survey and/or subject to penalty assessment are as follows: 1290-Background Studies Required-144g.60 Subdivision 1 The details of the violations noted at the time of this follow-up survey completed on March 27, 2025, (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. The total amount of potential f ines that may be assessed related to these correction orders is $3,000.00. M DH is not imposing these fines against your license at this time. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the provisional licensee must document actions taken to comply with the correction orders and immediately correct any reissued orders outlined on the state form; however, plans of correction are not required to be submitted for approval. I f corrections are not made, MDH may impose fines as described above and in accordance with Minnesota Statutes 144G. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees An equal opportunity employer. Letter ID: 175O Rivers of Life April 29, 2025 Page 2 that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm CONDITIONAL LICENSE ISSUED: MDH will extend the provisional conditional assisted living with dementia care facility license for Rivers of Life, for an additional 30 calendar days from the date of this notice. At an unannounced point in time, within the 30 calendar days, MDH will conduct a follow-up survey, as defined in Minn. Stat. § 144G.30, Subd. 6. Based on the results of the follow-up survey, MDH will determine if Rivers of Life i s in substantial compliance. The following conditions have been removed, effective April 29, 2025: a. Consultant: Rivers of Life w ill contract with an RN to provide consultation concerning all resident(s) to whom Rivers of Life p rovides provisional licensed assisted living services under the conditional license. The consultant must have access to all resident(s) receiving services from Rivers of Life. The consultant will conduct initial and ongoing evaluations of the provider. Direct resident observation may be required based on the consultant’s judgement or at the discretion of MDH. The RN must not have any affiliation with Rivers of Life a nd MDH must review the RN’s credentials and approve the selection. Rivers of Life is responsible for the expense of the contract with the RN. The main purpose of the consultant is to provide guidance to Rivers of Life i n an effort to help Rivers of Life align their practices with the requirements of Minn. Stat. §§ 144G.01 – 144G.9999 and to provide oral and written reports to MDH noting progress toward substantial compliance and/or concerns about observations. Rivers of Life w ill develop and implement policies, procedures, and processes specific to the offered services in accordance with the guidance provided by the consultant to ensure ongoing monitoring and substantial compliance with statutory requirements. b. Reports: The RN consultant will provide MDH with regular reports at intervals specified by MDH. Reports will begin on a weekly basis until MDH notifies Rivers of Life a nd the RN consultant about a change. Each report will be electronically submitted to: Brandon Mueller, State Evaluation Team, Health Regulation Division, at brandon.w.mueller@state.mn.us and can be reached at 651-247-2064 (office) with questions about reports. The content of the reports will include information such as: i. Progress towards correction of orders; ii. Observations of staff delivering assisted living services and the level of competency observed; iii. Conversations with residents and family members about satisfaction with assisted Rivers of Life April 29, 2025 Page 3 living services; iv. Conversations with staff about their level of knowledge about the tasks they perform, the people they serve and the health professionals who delegate to them; v. Overall impressions about the quality of the assisted living services delivered; vi. Overall impressions about the dignity with which the residents and their family members are treated; vii. Concerns; and viii. Any other information requested by the Department or considered important by the RN consultant(s). The following conditions will continue to be in effect on the provisional conditional assisted living facility with dementia care license: a. No new substantiated maltreatment allegations: I f any new investigations begin in the conditional license period, and the allegations are substantiated, MDH may pursue additional enforcement actions up to and including immediate temporary suspension and revocation of the license. b. No new admissions: R ivers of Life w ill continue to not admit any new residents under its conditional assisted living facility license until MDH removes the “no new admissions” condition. c. Monitoring visits: M DH may make unannounced monitoring visits to assess the progress of Rivers of Life to correct the violations cited during the survey as well as to determine the overall practice of Rivers of Life in meeting the needs of the people it serves. In addition, the Office of Ombudsman for Long-Term Care (OOLTC) may also make unannounced monitoring visits to determine the level of satisfaction of those people who receive provisional licensed assisted living services. The OOLTC will share their findings with MDH. d. Follow-up survey: A t the time of the follow-up survey, MDH may pursue additional enforcement actions, up to and including immediate temporary suspension or revocation of the provisional license if MDH identifies any level 3 or 4 violations or widespread care related violations. e. Corrective Action Plan: R ivers of Life w ill continue to work within a corrective action plan (CAP). The CAP is a working document that includes at least the following information: i. A statement of the concern ii. A description of what will happen to correct the concern iii. A target date for when each correction will be complete iv. Who is responsible to make sure it happens v. Current status of correction work vi. Description of a plan to monitor and ensure ongoing substantial compliance for each corrected order. RESULTS OF FOLLOW-UP EVALUATION DURING THE CONDITIONAL PROVISIONAL LICENSE PERIOD: MDH will determine if Rivers of Life i s in substantial compliance based on the results of the follow up survey. Rivers of Life April 29, 2025 Page 4 MDH will make this determination within the 30-day conditional provisional license period. If MDH determines Rivers of Life is in substantial compliance on the follow up survey, MDH will remove the conditions and grant the assisted living facility license to Rivers of Life. If MDH determines Rivers of Life is not in substantial compliance, MDH may deny the license pursuant to Minn. Stat. § 144G.16, Subd. 3 (b) (2). REQUEST FOR RECONSIDERATION: Pursuant to Minn. Stat. §144G.16, Subd. 4, if a provisional licensee whose assisted living facility license has been denied, or extended with conditions, disagrees with the action taken against the provisional license under this section, the provisional licensee may request a reconsideration no later than 15 calendar days after provisional licensee receives notice of the action. This is your only ability to request a reconsideration under this enforcement action. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact Jodi Johnson directly at: 507-344-2730. Sincerely, Rick Michals, J.D. Executive Regional Operations Manager HHH PRINTED: 04/29/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.