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February 2, 2023 Abiodun Akinbolu, Authorized Agent Excellent Care Services 3003 43rd Street Northwest, Suite 106 Rochester, Minnesota 55901-2477 License Number: 1072127(245D – HCBS) CORRECTION ORDER Dear Abiodun Akinbolu: On January 25, 2023, a licensing review of Excellent Care Services, located at 3003 43rd Street Northwest, Suite 106, Rochester, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statues, section 245D.051, subdivision 1. Violation: For one of one person whose record was reviewed (P1), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. “Target Symptom” refers to any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that have been identified for alleviation. The license holder was assigned responsibility for administration of P1’s medication in the support plan. P1 was prescribed a psychotropic medication. The license holder failed to maintain documentation that included a description of the target symptoms that the psychotropic medication was to alleviate. Corrective Action Ordered: P1 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet assessment and initial service planning requirements for intensive services as required. a. The license holder completed assessments for P1, however, the license holder failed to ensure the assessments produced information that described P1’s overall strengths, functional skills and abilities to self-manage symptoms or behaviors that may otherwise result in suspension or termination of services by the license holder or other symptoms or behaviors that may jeopardize the health and welfare or the person or others. b. The license holder failed to have a discussion within 45 days of P1’s service initiation about how technology might be used to meet P1’s desired outcomes and include a summary of this discussion in the in P1’s support plan. Corrective Action Ordered: P1 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statues, section 245D.09, subdivision 4. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. The license holder failed to provide SP1 and SP2 with orientation training on strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities within 60 calendar days of hire. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 and with the above mentioned required training. The license holder no longer employs SP1. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statues, section 245D.09, subdivision 5. Violation: For two staff persons whose record was reviewed (SP1 and SP2), the license holder did not provide annual training as required. “Annual” and “annually” means prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP1 and SP2 with annual training in the following areas: · 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 and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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 health relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with the above mentioned required annual trainings. The license holder no longer employs SP1. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. 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 Amber Nielsen at 651-431-3661 or amber.n.nielsen@state.mn.us as soon as possible. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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