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April 6, 2023 Juliana Okoro, Authorized Agent 1-Dominion Home Health Care Inc 1401 Silver Lake RD NW STE 7 New Brighton, MN 55112 License Number: 1094229 (245D - HCBS) CORRECTION ORDER Dear Juliana Okoro, On March 10, 2023, a licensing review of 1-Dominion Home Health Care, Inc., located at 1401 Silver Lake Road NW, Suite 7, New Brighton, 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 3. Violation: For three of five persons whose records were reviewed (P1, P2, and P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. The license holder failed to include an individualized assessment of P1 and P2’s susceptibility of abuse. · P1’s IAPP stated that P1 was not susceptible to abuse or at risk of abusing other vulnerable adults, however, this assessment was not consistent with information reviewed elsewhere in P1’s record. The support plan completed by P1’s case manager indicates that P1 was at risk due to self-injurious behaviors. · P2’s IAPP stated that P2 was not susceptible to abuse or at risk of abusing other vulnerable adults; however, this assessment was not consistent with information reviewed elsewhere in P2’s record. The support plan completed by P2’s case manager stated that P2 had mental health issues that made him/her at risk of self-abuse. The support plan also indicated that P2 was at risk of financial exploitation. b. P4 received individualized home supports and night supervision from the license holder. The license holder developed an IAPP for P4; however, the license holder failed to document the statement of measures that would be taken to minimize the risk of abuse within the scope of each service P4 was receiving. c. The license holder failed to review P2’s IAPP at least annually with P2’s interdisciplinary team. The license holder developed P2’s IAPP on October 19, 2019. The license holder did not review the IAPP until October 27, 2021. Repeat Violation: The license holder was cited for a similar violation in a correction order dated July 12, 2019. Corrective Action Ordered: within 60 days of this order, you must: · review and revise the IAPPs for P1, P2, and P4 to include an individual assessment and statement of specific measures within the scope of each service the person receives; and · review P1, P2, and P4’s IAPPs with the person and the person’s case manager. You must document this review; and · submit the revised IAPPs for P1, P2, and P4, and evidence the IAPPs have been reviewed by the person and the person’s case manager. On an ongoing basis, you must maintain compliance as required. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For five persons whose record was reviewed (P1-P5), the license holder did not provide each person, or the person’s legal representative, as applicable, with a written notice that identifies the service recipient rights annually. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder failed to provide P1-P5 with a written notice of the service recipient rights and an explanation of those rights on an annual basis. b. The written notice the license holder provided to P1-P5 failed to include the right of access the person’s personal possessions at any time, including financial resources. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an audit of the records of all persons served by your program to ensure each person or the person’s legal representative, as applicable, was provided the written notice within the past 12 months that included the right detailed above; and · for persons or legal representatives that were not provided a written notice within the past 12 months, you must provide those persons and legal representatives with a written notice that includes the above-mentioned right. You must maintain documentation of the person’s or the person’s legal representative’s receipt of a copy and an explanation of the rights. On an ongoing basis, you must provide written notice of service recipient rights as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P4), the license holder did not provide services in response to the person’s identified needs, interests, and preferences as required for each service.
The license holder provided multiple services to P4. The license holder failed to ensure that P4’s support plan addendum identified how services were provided for each service, including, when, and by whom. Corrective Action Ordered: Within 30 days of receiving this order, you must review and update P4’s support plan addendum to include the information listed above. On an ongoing basis, you must maintain compliance as required. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two person whose record was reviewed (P1, P2), the license holder did not complete assessments for intensive service planning as required. The license holder failed to complete assessments in the following areas for P1 and P2: · the person’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 medication or treatment orders, preventative screenings, and medical and dental appointments; · the person’s ability to self-manage 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; · the person’s ability to self-manage symptoms or behavior that may 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 welfare of the person or others; and · assessments must produce information about the person that describes the person’s overall strengths, functional skills and abilities, and behaviors or symptoms. Corrective Action Ordered: within 60 days of receiving this order, you must: · complete the required assessments for P1 and P2 that produce information about the person that describes the person’s overall strengths, functional skills, and abilities; · review the results of the assessments for P1 and P2 with the person, the person’s case manager and members of the support team. You must document this review; and · submit P1 and P2’s assessments and evidence of the review of these assessments by the person, case manager and other support team members, as applicable, to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 andP2), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a as required. For P1 and P2, the license holder failed to develop service outcomes and failed to document the following supports and methods to accomplish outcomes: · the methods or actions that will be used to support the person and to accomplish the service outcomes including: o information about changes or modifications to the physical and social environments; o equipment and materials required; o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which the progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: within 60 days of receiving this order, you must: · develop and maintain a service plan that documents the service outcomes, supports and methods listed above for P1 and P2; · submit evidence to your licensor that the service outcomes for P1 and P2 were developed, and the supports and methods were documented. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P5), the license holder did not evaluate with the person the identified positive support strategies at least every six months as required. The license holder failed to evaluate the identified positive support strategies with P5 at least every six months as required. The license holder developed positive support strategies with P5 on July 21, 2021. The license holder did not review the strategies with P5 until August 16, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain documentation of the evaluation of the identified positive supports strategies at least every six months as required in this subpart. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of four staff persons whose records were reviewed (SP3), the license holder did not provide orientation training as required. SP3’s hire date was June 11, 2022. The license holder failed to provide orientation training on the strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. At the time of the licensing review, the license holder had not provided this training to SP3. Repeat Violation: The license holder was cited for a similar violation in a correction order dated July 12, 2019. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP3 with the above-mentioned training and submit evidence to your licensor that SP3 has received the training. On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP4), the license holder did not provide annual training as required.
a. The license holder failed to provide SP4 with annual training in 2020 and in 2021 in the following areas. The license holder later provided these trainings to SP4 June 16, 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 (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; · 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; and · basic first aid. b. The license holder failed to provide SP4 with annual training on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. At the time of the licensing review, the license holder had not provided this training to SP4. c. The license holder stated that they provided training to SP4 in 2020 and in 2021 on sections 245A.65, and 626.557, governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. Although the license holder stated that they provided this training, there was no record of the training in SP4’s record. DHS licensors were unable to determine if or when this training occurred in 2020 or in 2021. The license holder later provided this training to SP4 on June 16, 2022. Corrective Action Required: Within 60 days of receiving this order, you must: · provide SP4 with training on strategies to minimize sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; · audit the annual training records for all staff to ensure all staff have received annual training on all the required topics in the past twelve months; · based on the results of the audit, provide annual training to all staff who have not received training on all the annual training topics in the past twelve months; and · submit the following to your licensor: o evidence that SP4 received training on the strategies to minimize sexual violence; o results of the audit of the staff annual training records and evidence that any staff who had not received training on a required annual training topic in the past twelve months was provided the training. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (f), and section 245A.07, subdivision 3, paragraph (d). Violation: For one staff person whose record was reviewed (SP4), the license holder did not submit a background study request to DHS for the staff person as required. SP4 began a position allowing direct contact with persons served by the program in November 2019. The license holder had inconsistent dates of hire listed in SP4’s personnel record, including November 1, 2019, November 2, 2019, and November 19, 2019. DHS licensors were unable to determine what date in November 2019 was SP4’s hire date. Additionally, the license holder listed inconsistent dates in SP4’s personnel record for SP4’s first date of supervised direct contact, including November 2, 2019 and November 22, 2019. DHS licensors were unable to determine what date was SP4’s date of first supervised direct contact. The license holder failed to submit the background study for SP4 prior to the staff person beginning a position allowing direct contact with persons served by the program. Corrective Action Ordered: On an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C as required. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 3, item B, subitem (11). Violation: For five persons whose record was reviewed (P1-P5), the license holder did not maintain progress or daily log notes that are recorded by the program. The license holder failed to maintain progress or daily log notes for P1-P5. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining progress or daily log notes that are recorded by the program as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not maintain personnel records as required. a. The license holder had several documents in SP4’s personnel record that listed inconsistent dates of hire. Documents listed November 19, 2019, November 2, 2019, and November 1, 2019 as SP4s date of hire. The license holder failed to maintain SP4’s date of hire in SP4’s personnel record. b. SP4’s personnel file contained documents that listed conflicting dates for SP4’s first date of supervised direct contact and SP4’s first date of unsupervised direct contact. SP4’s personnel record contained a document titled “New Employee Training Plan.” This document stated that SP4’s first date of direct contact was November 22, 2019 and the first date of unsupervised direct contact was November 24, 2019. SP4’s personnel record also contained a document titled “On-The-Job Training Supervised.” This document stated that the staff person received supervised training with the person served at the location where services were provided. This document was dated November 2, 2019. The license holder failed to maintain documentation of the date of SP4’s first supervised direct contact and the date of SP4’s first unsupervised direct contact with a person served by the program. c. The license holder failed to maintain the date training was completed, the number of hours of training per subject area, and the name of the trainer or instructor in SP3 and SP4’s personnel records for each required training subject area.
Repeat Violation: The license holder was cited for a similar violation in a correction order dated July 12, 2019. Corrective Action Ordered: On an ongoing basis, you must maintain the following training information in each staff person’s personnel record as required in this subdivision: · the date of hire; · the date the training was completed; · the number of hours per subject area; · the name of the trainer or instructor; · date of first supervised direct contact with persons served; and · date of first unsupervised direct contact with persons served. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. While the license holder did establish a policy titled “Maltreatment of Vulnerable Adults Mandated Reporting Policy”, the license holder failed to identify the following: · the secondary person or position to whom internal reports may be made; · the secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5; and · the secondary person or position who will ensure that, when required, internal reviews are completed. This section requires that the secondary person must be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. The license holder listed “program director” as the primary position and listed SP2’s name as the secondary person for the requirements listed above. During the licensing review, the license holder stated that SP2 was the program director. The license holder listed the same individual as both the primary and secondary person or position. Corrective Action Ordered: Within 30 days of receiving this order, you must establish and maintain a policy that identifies a secondary person or position responsible for requirements identified above. Additionally, you must provide this policy to all staff persons and persons served. On an ongoing basis, you must maintain this policy 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at Renae.S.Dressel@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, please mail of fax using the information below: Commissioner, Department of Human Services ATTN: Renae Dressel Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Fax: 651-431-7673 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 me at 651-431-2661 as soon as possible. Renae Dressel, Human Services Licensor Licensing Division Office of Inspector General
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