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October 4, 2022
Eka Alkaabi, Authorized Agent Eka Alkaabi 1576 35th Avenue South Moorhead, MN 56560 License Number: 1103112 (245D - Home and Community-Based Services) License Number: 1103586 (Adult Foster Care) NOTICE OF NONCOMPLIANCE WITH TERMS OF A CONDITIONAL LICENSE AND CORRECTION ORDER Dear Eka Alkaabi: On May 18, 2022, the Commissioner of the Department of Human Services (DHS) issued an Order of Conditional License to Eka Alkaabi, located at 1576 35th Avenue South, Moorhead, Minnesota. On, August 9, 2022, a licensing review of Eka Alkaabi, was conducted 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 and the terms of the Order of Conditional License issued on May 18, 2022. As a result of this licensing review, DHS determined 11 home and community-based services licensing violations, and noncompliance violations 1 terms in the Order of Conditional License. As a result, DHS is issuing this order which requires you to take the corrective action as described under each violation. Noncompliance with the Terms of the Order of Conditional License
During a licensing review on August 9, 2022, DHS determined that you failed to follow 1 of 5 terms of the Order of Conditional License that is in place from May 18, 2022 to May 17, 2024. 1. The license holder failed to comply with term 4 of the Order of Conditional License Term 4 required within 60 days of receiving the Conditional Order dated May 18, 2022 that the license holder must: · submit a complete list of all direct care staff currently and previously employed within the past two years, including date of hire, date of first supervised direct contact with a person served by the program, date that the background study was initiated, date the background study was completed, and, if applicable, date ended. · develop and maintain a training curriculum for each training topic required to be provided to staff persons; · complete an audit of all participant and personnel records according to your written plan; · submit the results of the audit to your DHS licensor; and · submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. The license holder failed to submit, develop and complete the above mentioned items. Corrective Action Required: Within 30 days of receipt of this order, you must complete the above mentioned requirements. Compliance with this term will be reviewed onsite. Program Coordination, Evaluation, and Oversight 1. Required compliance: Minnesota Statutes 245D.081, subdivisions 2 and 3. Violation: The license holder did not meet the requirements of program coordination, evaluation and oversight. a. The license holder failed to ensure that the designated coordinator (SP3), provided supervision, support and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s coordinated service and support plan and the coordinated service and support plan addendum; · instruction and assistance to direct support staff implementing the coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. b. The license holder failed to ensure that the designated manager (SP4) provided program management and oversight of the services provided by the license holder, that include: · ensure the duties of the designated coordinators are fulfilled according to the requirements in subdivision 1; and · 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 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
See citations 2 through 11 for the designated coordinator and designated manager’s failure to provide the above stated requirements. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must follow the corrective action ordered throughout this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required. Service Recipient Violations 2. Citation: Minnesota Statutes, section 245D.071, subdivision 2. Violation: For one of one person whose record was reviewed (P1), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder developed and maintained an IAPP for P1 in their service recipient record. The license holder failed to include statements of measures, including specific actions, the program would take to minimize the risk of abuse within the scope of the licensed services. Additionally, the license holder documented in P1’s IAPP that P1 runs out of medications often and that P1 refuses medications. Through conversation with the license holder, it was determined that statement was not accurate. The license holder failed to document an individualized assessment related to P1’s susceptibility of abuse. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must document in P1’s individual abuse prevention plan consistent information with P1’s record. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (d). Violation: For one person whose records were reviewed (P1), the license holder did not meet service planning requirements for intensive support services. The license holder met with P1, P1’s case manager, and other members of P1’s support team on June 24, 2022. The license holder failed to: · hold a discussion of how technology might be used to meet P1’s desired outcomes; and · include a summary of this discussion in P1’s coordinated service and support plan (CSSP) addendum that includes a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must · meet with P1, P1’s case manager, and members of the support team to determine the above mentioned items and to have a discussion about how technology might be used to meet the person’s desired outcomes; and · include a summary of the technology discussion in P1’s coordinated service and support plan or support plan addendum (CSSPA). Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. Health Needs: 4. Citation: Minnesota Statues, section 245D.05, subdivision 2. Violation: For one person whose records were reviewed (P1), the license holder did not implement medication administration procedures as required. The license holder was responsible for administering P1’s medications. The license holder had the medication titled Flexiril documented on the MAR for the months of February, April and June 2022, and the months of March, May and July 2022 had Flexiril documented on the MAR, but was then crossed out with an “x.” The license holder failed to ensure notations of when a medication or treatment was started, administered, changed or discontinued was documented in P1’s medication administration record. Through conversation with the license holder it was determined that the medication was no longer being given because the prescription only contained 15 pills and all 15 pills had been administered, additionally no refills were authorized. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. 5. Citation: Minnesota Statues, section 245D.05, subdivision 4. Violation: For one person whose records were reviewed (P1), the license holder did not review medication administration records as required. The license holder was assigned responsibility for medication administration for P1. SP3 completed a medication administration record (MAR) review on July 15, 2022 and documented that all medications were correctly listed on the MAR based on the current prescription label or prescription order. However, while reviewing the MARS, a medication titled Flexiril was listed on P1’s MAR to be given as needed for February, April, and June 2022, the medication was documented as being administered on April 10, 2022. The prescription for the Flexiril had expired on February 3, 2022, therefore the license holder gave the medication after the expiration date. The license holder failed to review medication administration records and report medication and treatment issues as required. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receipt of this order, you must: · complete and document a medication administration record review for P1 to ensure all of P1’s current medications are listed correctly, based on current prescriber’s orders; · if any discrepancies are found, document them on the medication administration record review and correct them on P1’s medication administration record based on the current prescriber’s orders; and · maintain documentation of the medication administration reviews as required in section 245D.095, subdivision 3. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. 6. Citation: Minnesota Statutes, section 245D.051. Violation: For one persons whose record was reviewed (P1), the license holder did not meet the requirements for psychotropic medication use and monitoring. P1 was prescribed multiple psychotropic medications. The license holder failed to develop, implement, and maintain documentation that includes a description of the target symptoms that each psychotropic medication is used to alleviate. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must develop, implement, and maintain documentation that includes a description of the target symptoms for each psychotropic medication is used to alleviate. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. Staffing Standards 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of four staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. The license holder was unable to provide a hire date for SP2; however, at the time of the licensing review the following orientation training had not occurred: · the job description and how to complete specific job functions including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies; · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder provided orientation to the job description only on August 6, 2022. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with the above mentioned training. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required. a. Through conversations with the license holder, it was determined that SP2 is responsible for P1’s services while the license holder is not present at the program. The license holder failed to provide SP2 with the following training before having unsupervised direct contact with a person served by the program: · orientation to the individual service recipient needs; · the person’s coordinated service and support plan (CSSP) or coordinated service and support plan addendum (CSSPA); · the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. b. The license holder failed to provide SP1 and SP2 with instructions on medication administration procedures, established for P1 before allowing SP1 and SP2 to be responsible for administering medications. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with an orientation to the requirements stated above. Additionally, you must ensure medication administration training is from a training curriculum developed by a registered nurse or appropriate licensed health professional and the training curriculum must incorporate an observed skill assessment conducted by the trainer to ensure unlicensed staff demonstrate the ability to safely and correctly follow medication procedures. You must maintain documentation of the training curriculum, according to 245D.095. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis you must provide orientation training as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose record were reviewed (SP1 and SP2), the license holder did not maintain personal records as required. a. The license holder failed to maintain a personnel record for SP2 that included: · the date of hires; and · orientation and annual training that included: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. b. The license holder failed to maintain documentation in SP2’s personnel record sufficient to determine the date of first supervised direct contact with a persons served by the program, and the date of first unsupervised direct contact with a person served by the program. Repeat Violation: In an Order of Conditional License DHS issued May 18, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis you must provide orientation training as required in this subdivision. Program Policies and Procedures 10. Citation: Minnesota Statues, section 245D.061, subdivision 9. Violation: The license holder did not develop policy and procedures that promoted service recipient rights and protected health and welfare during the emergency use of manual restraints as required. The license holder developed a policy and procedure that allowed staff to use manual restraints on an emergency basis; however, the license holder failed to develop a policy and procedure that included instructions for safe and correct implementation of the allowed manual restraint procedures. Corrective Action Ordered: Within 30 days of receiving this order, you must revise and implement the above stated policy that includes instructions for safe and correct implementation of the allowed manual restraint procedures. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. 11. Citation: Minnesota Statutes, section 245D.11, subdivision 2, paragraph 5, 6 and 7. Violation: The license holder failed to establish policies and procedures for providing intensive services, as required. a. The license holder established a policy titled “Emergency Response, Reporting & Review Policy,” however the license holder failed to: · establish a written plan for responding to the following emergencies: o Fires; o Severe weather; o Power failures; o Emergency shelter; o Emergency evacuation; o Temporary closure or relocation. · identify within the policy and procedures, who was responsible for completing the review of all emergencies and within how many days the review would be completed; and · establish a record-keeping system for the emergency reports. b. The license holder established a policy titled “Incident Response, Reporting and Review Policy;” however, the license holder failed to: · include a detailed plan for responding to incidents, including: o the contact information to the mental health crisis intervention team when staff believe a person is experiencing a mental health crisis; o contact information for non-emergency incidents requiring law enforcement, and contact information for non-emergency incidents requiring the fire department; o when a person is determined to be missing or has an unexplained absence, staff will call 911 and after contacting law enforcement staff are to notify someone within the company to determine if additional staff are needed to assist in the search. The license holder failed to identify the name and/or title of that staff person. · include who the review will be completed by and within how many days the review of the incidents would be completed; and · identify the name or position title of the staff was responsible for conducting an internal review of deaths and serious injuries and within how many days the internal review would be completed. Corrective Action Ordered: Within 30 days of receiving this order, you must revise and implement the above-stated policy and procedures. Continued compliance monitoring will be conducted during onsite reviews. On an ongoing basis, you maintain compliance as required. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. A. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible.
Sincerely, Liz Schiefelbein, Senior HCBS Licensor Licensing Division Office of Inspector General 651-431-2738
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