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February 27, 2023 CERTIFIED MAIL Muhamed Mohamud Caaje, Authorized Agent Minnesota Multi Cultural Health Services LLC 4111 Central Avenue Northeast Suite 208E Columbia Heights, Minnesota 55421 License Number: 1087769 (HCBS) ORDER OF CONDITIONAL LICENSE Dear Muhamed Mohamud Caaje: The Department of Human Services (DHS) is placing your license to provide home and community-based services (HCBS) at 4111 Central Avenue Northeast, Suite 208E, Columbia Heights, Minnesota on conditional status for two years, beginning February 27, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with HCBS licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On February 15, 2023, a DHS licensor conducted a licensing review at your facility located at 4111 Central Avenue Northeast, Suite 208E, Columbia Heights, Minnesota. As a result of this licensing visit, the DHS licensor determined that your program failed to comply with the laws and rules that apply to licensed HCBS programs, citing 12 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: o Failure to provide relevant information and give true or accurate information to the Commissioner regarding compliance with applicable laws or rules; o Failure to ensure the exercise and protection of a person’s service-related and protection-related rights; o Failure to provide services in response to the person's identified needs, interests, preferences, and desired outcomes; o Failure to meet initial service planning requirements; o Failure to meet service plan review and evaluation requirements; o Failure to designate a qualified and competent staff person(s) to fulfill the responsibilities for coordination and evaluation of individual service delivery and program management and oversight; o Failure to maintain personnel records; and o Failure to provide required orientation and annual training to staff persons. · Chronicity: o July 5, 2017: HCBS license issued o August 29, 2018: Correction Order – 1 violation o February 27, 2023: Conditional License (this order) – 12 violations · Severity: Many of the violations that led to the condition of your license relate to the health and safety of persons served. o 1 violation was related to the rights of a persons served o 9 violations were related to the manner in which services were not provided according to licensing standards o 2 violations were related to the program coordination, evaluation, and oversight of your program Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide HCBS is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: For three of three persons whose records were reviewed (P1 through P3), the license holder did not meet the requirements of positive support strategies and person-centered planning as required. The license holder failed to develop and implement positive support strategies for P1 through P3 according to the standards in subpart 2, and failed to incorportate principles of person-centeredness into the services provided to P1 through P3. Additionally, the license holder failed to evaluate with P1 through P3 identified positive support strategies at least every six months. Statute Violated: Minnesota Rules, part 9544.0030, subparts 1 and 2. 2. Violation: For one person whose record was reviewed (P1), the license holder did not review the individual abuse prevention plan as required. The license holder failed to review P1’s individual abuse prevention plan annually in 2020, 2021 and 2022. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). 3. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not provide the person or their legal representative with a written notice that identified the service recipient rights as required. a. The license holder failed to provide P1 and P3 with service recipient rights annually in 2020, 2021 and 2022. b. The license holder failed to provide P2 with service recipient rights within five days of service initiation. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). 4. Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning requirements for basic support services as required. The license holder failed to review and revise as needed P2’s preliminary support plan addendum within 60 calendar days of service initiation. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (b) and (c). 5. Violation: For two persons whose record were reviewed (P1 and P3), the license holder did not, within the scope of services, complete assessments as required. a. The license holder failed to complete assessments for P1 that included information about the person that described the person's overall strengths, functional skills and abilities, and behaviors or symptoms annually in 2020, 2021 and 2022. b. The license holder completed assessments for P3 in 2022; however, failed to include information about the person that described the person's overall strengths, functional skills and abilities, and behaviors or symptoms. In addition, the license holder failed to complete assessments for P3 in 2020 and 2021. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). 6. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet service plan review and evaluation requirements. The license holder failed to meet with P1 and P3’s team annually as required in 2020, 2021 and 2022. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (a). 7. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet service plan review and evaluation requirements. The license holder failed to provide reports regarding P1 and P3’s progress toward achieving the identified outcomes that: · summarized the person’s progress toward achieving the identified outcomes; · made recommendations; and · identified the rationale for changing, continuing, or discontinuing implementation of supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b). 8. Violation: For two of four 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 strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities in 2020, 2021 and 2022. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. 9. Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide annual training as required. The license holder failed to provide SP3 and SP4 with the following annual training in 2020, 2021 and 2022: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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; · 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; · 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 the 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; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · basic first aid. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. 10. Violation: For one person whose record was reviewed (P2), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P2’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation; · grievance policy; · temporary service suspension policy; · service termination policy; and · emergency use of manual restraints policy. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). 11. Violation: The license holder did not ensure the delivery and evaluation of services provided were coordinated by the designated staff persons as required. The designated coordinator identified by the license holder (SP5 through SP8) failed to provide 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; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · 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; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. Statute Violated: Minnesota Statutes, section 245D.081, subdivision 2. 12. Violation: The license holder did not ensure that the designated managerial staff persons provided program management and oversight of the services provided as required. The designated managers identified by the license holder (SP5 and SP6) failed to provide program management and oversight of the services provided by being responsible for the following: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program; · ensuring the duties of the designated coordinator are fulfilled; · ensuring staff competency requirements are met. The failure to provide program management and oversight of the services provided is evidenced in citation 1 through 11. Statute Violated: Minnesota Statutes, section 245D.081, subdivision 3. CORRECTIVE ACTION REQUIRED You must correct the violations cited above across all services, persons, staff and program under this license. If you fail to demonstrate substantial compliance with Home and Community-Based Services licensing requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the HCBS licensing rules and statutes, you are required to comply with the following terms: 1. Within 10 days from receipt of this order, you must provide written notification of the conditional status of your license to all service recipients currently receiving home and community based services from Minnesota Multi Cultural Health Services LLC. A copy of the notification must also be provided to their legal representatives and case managers. A copy of the notice must also be maintained in the person’s record. The notification must include an offer to provide a copy of the Order of Conditional License upon request. Within 30 days from receipt of this Order, you must submit a copy of the notice and a list of all persons that received the notice to your DHS licensor. Every 30 days after, you must submit a list of current persons served to your DHS licensor. 2. Within 20 day from receipt of this Order, you must submit qualified designated coordinator/s and designated manager/s, other than SP5 through SP8. You must include how the designated coordinator/s and designated manager/s meet the statute requirements in Minnesota Statues, section 245D.081. 3. Within 30 days from receipt of this Order, you must correct all violations cited in this Order and submit a report detailing how the violations have been corrected. 4. Within 30 days from receipt of this Order, you must submit a written plan to your licensor detailing how you will audit all participant and personnel records for compliance with all applicable rules and statutes. This plan must include specific dates for when you will submit the audits to your DHS licensor; and who is responsible for the audits. Audits must occur no less than once per quarter for the duration of the conditional license. 4. Within 60 days of receiving this order, you must: · Complete the first audit of all participant and personnel records according to your written plan; · Submit the results of your audit to your DHS licensor; and · Submit the date to your licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 5. You may not admit new participants to your program from the date of this order until the time your conditional license expires or you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. Program is defined by Minnesota Statues, section 245D.02, subdivision 26 meaning either the nonresidential or residential programs as defined in section 245A.02, subdivisions 10 and 14. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Admission of any new participant during the duration of the conditional license is only allowed with prior approval from DHS. Submissions required as part of a corrective action ordered must be sent to your licensor at: 1. By secure email at lindsay.norris@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: Lindsay Norris Licensing Division PO Box 64242 St. Paul, MN 55164-0242 651-431-7673 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for 2 from that date. You continue to be required to comply with all HCBS laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · HCBS license holders are required to follow Minnesota Statutes, chapters 245A, 245C and 245D . · The timeline to request reconsideration of a conditional license order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Christala Culhane, HCBS Supervisor, at 651-431-6541. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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