|
February 6, 2023 Samatar Dualeh, Authorized Agent Silver Mountain Home Health Care LLC 1603 Chicago Avenue Minneapolis, Minnesota 55404 License Number: 1081219 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Samatar Dualeh: On January 5, 6, and 9, 2023, a licensing review of Silver Mountain Home Health Care LLC, located at 1603 Chicago Avenue, Minneapolis, 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 Statutes, section 245A.65, subdivision 1. Violation: For one of three persons whose record was reviewed (P3), the license holder did not provide orientation to the license holder’s internal and external reporting procedures for alleged and suspected maltreatment as required. The license holder failed to provide P3 with orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. P3’s admission date was October 20, 2022. The “Policy Receipt and Signature Page” in P3’s file was signed by P3’s legal representative and case manager; however the only date was the case manager’s on January 6, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not develop, document and implement a policy and procedure for the emergency use of manual restraints as required. The license holder developed two policies for the emergency use of manual restraint: one that did all for the emergency use of manual restraints, and one that did not allow for the emergency use of manual restraints. The license holder was unable to ensure that both policies were not documented, implemented and distributed in the program. Corrective Action Ordered: Within 30 days of receipt of this order, you must revise your emergency use of manual restraint policy to state whether you allow or do not allow the emergency use of manual restraints in your program. You must ensure all service recipients receive a copy of this policy and all staff are trained on this policy. On an ongoing basis, you must maintain compliance was required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not provider services in response to the person’s identified needs, interests and preferences as required for each service. a. The license holder failed to provide person-centered service planning when the license holder completed a coordinated service support plan addendum form for P1 and P2 entitled “Coordinated Service and Support Plan (CSSP) Addendum” that was not specific to each person’s needs and how each service would be provided. The wording in both P1 and P2’s plans were similar throughout the document. P1 no longer receives services from the license holder. b. P1, P2, and P3 received multiple services from the license holder. The license holder failed to ensure that P1’s, P2’s and P3’s coordinated service and support plan addendum identified how services were to be provided for each service, including how, when and by whom. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · review and update P2’s and P3’s coordinated service and support plan to include the information listed above; · submit the updated coordinated service support plan addendums for P2 and P3; · Audit all of your person served records to ensure compliance with this subdivision. On an going basis, you must maintain compliance as required with this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not meet service planning and delivery requirements for a basic service as required. a. The license holder failed to review and revise as needed P1, P2 and P3’s preliminary coordinated service support plan addendums within 60 days of service initiation. b. P1 and P2’s coordinated service support plan addendums stated that annual progress reports would be provided to their support teams. The license holder failed to provide these reports to P1 and P2’s teams annually. Corrective Action Ordered: After completing the coordinated services support plan addendums order in citation (3), you must review and revise as needed P2 and P3’s plans within 60 days. In addition, you must provide progress reports to P2’s support team. On an ongoing basis, you must maintain compliance as required with this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 24, 2019. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder failed to meet service planning and delivery requirements for an intensive service. The license holder provided basic and intensive services to P3. The license holder failed to complete the following: · Assessments in the following areas: o P3’s ability to self-manage health and medical needs to maintain or improve physical, mental and emotional well-being including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of treatments orders, preventative screening, and medical and dental appointments; o P3’s ability to self-manager personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; o P3’s ability to self-manage symptoms or behavior that might otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and safety of the person others. · A 45 day planning meeting before providing 45 day of service, or within 60 calendar days of service initiation. The license holder did not meet with P3, P3’s legal representative, P3’s case manager, and other members of P3’s support team or expanded support team to determine the following based on the assessments listed above: o the person’s identified needs in the coordinated service support plan, and the requirements regarding service outcomes and reports and person centered planning and service delivery: § the scope of services to be provide to support the person’s daily needs and activities; § the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; § the person’s preferences for how services and supports are provide, including how the provider will support the person to have control over their schedule; § whether the current service setting is the most integrated setting available and appropriate for the person; § opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; § opportunities for community access, participation, and including in preferred community activities; § opportunities to develop and strengthen person relationships with other persons of the person’s choice in the community; § opportunities to seek competitive employment and work at competitively paying jobs in the community; and § how services would be coordinated across all other providers licensed under this chapter serve the person and members of the support team or expanded support team to sure continuity of care and coordinated of services for the person; and § a discussion of how technology might be used to meet the person’s desired outcomes and a summary of that discussion. Corrective Action Ordered: Within 30 days of receipt of this order, you must · complete the above mentioned assessments for P3 and submit a copy to your licensor; · review the assessment and the above mentioned information with P3’s support team; · audit all of your persons served record who receive an intensive service and ensure the above mentioned requirements have been completed. On an ongoing basis, you must meet service planning as delivery requirements for an intensive services as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not develop outcomes as required. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person centered planning including the following information: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment or materials required; o techniques that were consistent with the person communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved; · how data would be collected; · the projected starting date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons responsible for implementing the supports and methods. Corrective Action Ordered: Within 10 days of conducting the meeting with P3’s support team ordered in citation (4), you must develop P3’s outcome including the above mentioned information and submit a copy to your licensor. On an ongoing basis, you must maintain compliance with this subdivision as required. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. The license holder failed to provide the following orientation trainings to SP2 within 60 days of hire: · the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including: o safe medication assistance and administration; o safe transportation; o safety in emergencies reporting and review; · the safe and correct use of manual restraints on an emergency basis according to the requirements in sections 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, and · strategies to minimize the risk of sexual violation, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP2 with the above-mentioned trainings and document those trainings according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5. On an ongoing basis, you must provide orientation training as required in this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 24, 2019. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP1 with the following annual trainings: · 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; SP1 did not receive this training in 2020 and 2021; SP1 did receive this training on July 21, 2022; · basic first aid; SP1 did not receive this training in 2020, 2021, and 2022; and · strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities; SP1 did not receive this training in 2020, 2021, and 2022. Corrective Action Ordered: Within thirty days of receipt of this order, you must provide SP2 with the above mentioned trainings that have not been provided in the previous 12 months. On an ongoing basis, you must provide annual training as required in this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 24, 2019. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff persons whose record was reviewed (SP2), the license holder did not maintain personnel records as required. The license holder failed to document the number of hours per subject area on SP2’s training record. SP2’s training record recorded that all of SP2’s trainings were five minutes long. The license holder stated that each training was more than 5 minutes, but the instructor did not properly document the number of hours for each training. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 2. Violation: The license holder did not establish a policy and procedure for a simple complaint process as required. The license holder failed to establish a grievance policy and procedure that included the address for the highest level of authority in the program. Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise your grievance policy and procedure with the above-mentioned information. On an ongoing basis, you must maintain compliance as required with this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 24, 2019. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide policy and procedures affecting a person’s rights as required. a. The license holder failed to provide P2’s case manager with the policies and procedures affecting a person’s rights within five working days of service initiation. P2’s date of service initiation was October 3, 2020; however, these policies were not provided to P2’s case manager until December 24, 2020. b. The license holder failed to provide P3 and P3’s case manager with the policies and procedures affecting a person’s rights within 5 working days of service initiation. P3’s date of service initiation was October 20, 2022. The “Policy Receipt and Signature Page” in P3’s file was signed by P3’s legal representative and case manager; however the only date was the case managers on January 6, 2023. Corrective Action Ordered: On an ongoing basis, you must provide policies and procedures affecting a person’s rights as required in this subdivision. 12. Citation: Minnesota Rules Part 9555.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not identify and evaluate positive support strategies as required. The license holder failed to identify positive support strategies for P1 and P2. Corrective Action Ordered: Within 30 days of receipt of this order, you must identify positive support strategies for P2. You must review these positive support strategies with the person at least every six months. You must audit all of your person served records to ensure you have identified positive support strategies and review them every six months with the person. On an ongoing basis, you must maintain compliance with this subpart as required. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 24, 2019. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at diana.arnzen@state.mn.us or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Diana Arnzen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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 64953 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. Diana Arnzen, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-6638
|
