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February 28, 2023 Simon Nyamari, Authorized Agent Amani Health Care Services LLC 1705 Southcross Drive West 105 Burnsville, Minnesota 55306 License Number: 1091055 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Simon Nyamari: On February 14, 2023, a licensing review of Amani Health Care Services LLC, located at 1705 Southcross Drive West 105, Burnsville, 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 and the terms of the Conditional License issued on January 31, 2022. 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 2, paragraph (b). Violation: For two of four persons whose records were reviewed (P1 and P3), the license holder did not develop individual abuse prevention plans as required. a. The license holder identified that P1 was susceptible to physical and sexual abuse in P1’s individual abuse prevention plan dated July 13, 2022, however, the license holder failed to include a statement of specific measures the program would take to minimize the risk for abuse. b. The license holder identified that P3 was susceptible to physical and sexual abuse in P3’s individual abuse prevention plan dated August 9, 2022, however, the license holder failed to include a statement of specific measures the program would take to minimize the risk for abuse. Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise P1 and P3’s individual abuse prevention plans to include specific measures to minimize the risk for abuse when it has been assessed there is a risk of abuse. You must review all your person served individual abuse prevention plans to ensure compliance with this subdivision. On an ongoing basis, you must develop individual abuse prevention plans as required. Repeat Violation: The license holder was cited for a similar violation in correction orders dated March 1, 2019 and June 16, 2022 and an order of conditional license dated January 31, 2022. 2. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license did not develop, document and implement a policy and procedure for the emergency use of manual restraints as required. The license holder’s policy and procedure entitled “Emergency Us of Manual Restraint (EUMR) Allowed Policy” dated January 1, 2023, allowed for the emergency use of manual restraints, however, the license holder failed to include instructions for the safe and correct implementation of the allowed restraint procedures in this policy. Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise this policy with the above-mentioned requirement. On an ongoing basis, you must maintain compliance with as required with 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 provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as required. a. The license holder failed to ensure that P1’s and P3’s support plan addendums identified how services were provided for each service, including how, when, and by whom. b. The license holder failed to collect data for P2’s outcome. The license holder developed an outcome for P2 to complete a task once per week, and data was to be collected on the staff’s time sheets. The time sheets stated when P2 worked on the outcome, however, staff did not document if the task was completed once per week. Corrective Action Ordered: Within 30 days of receipt of this order, you must document the above information for P1, P2, and P3. In addition, you must audit all your person served records to ensure that each person as support plan addendum that identifies how each service is provided. For anyone receiving an intensive service, you must ensure data is being collected for their outcomes. 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 correction orders dated March 1, 2019 and June 16, 2022 and an order of conditional license dated January 31, 2022. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not meet service planning and delivery requirements for a basic service as required. P3’s Coordinated Service and Support Plan Addendum dated May 9, 2022, documented that P3’s team requested annual progress reports. The license holder failed to provide P3’s team with annual progress reports. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide P3’s team with a progress report. On an ongoing basis, you must maintain compliance as required with this subdivision. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation training as required. The license holder failed to provide SP1, whose hire date was July 26, 2022, with the following orientation training within 60 days of hire: · the license holder’s policy and procedure for responding to emergencies; and · strategies to minimize the risk of sexual violence, including concept of health relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP1 with the above-mentioned trainings. 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 March 1, 2019 and an order of conditional license dated January 31, 2022. 6. Citation: Minnesota Rules Part 9555.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not identify or evaluate positive support strategies for P1, P2, and P4. The license holder failed to identify positive support strategies for P1, P2, and P4. Corrective Action Ordered: Within 30 days of receipt of this order, you must identify positive support strategies for P1, P2 and P4. You must review these positive support strategies with the person at least every six months. You must audit all 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. 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. 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
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