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April 5, 2023 Demenia Gbarbea, Authorized Agent DeeNde LLC 3300 County Road 10 Suite 304K Brooklyn Center, Minnesota 55429 License Number: 1109824 (245D – HCBS) CORRECTION ORDER Dear Demenia Gbarbea: On March 20, 2023, a licensing review of DeeNde LLC, located at 3300 County Road 10 Suite 304K, Brooklyn Center, 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 245D.07, subdivision 1a. Violation: For one of two persons whose record was reviewed (P2), the license holder did not meet the requirements for person centered planning and service delivery. a. P2 experiences gender dysmorphia. In a document titled, “Coordinated Service and Support Plan (CSSP),” it is documented that, “It’s important to (P2) that others understand that he/she feels that he’s/she’s the wrong gender.” The license holder failed to provide person centered planning and delivery that respects P2’s history and dignity by not including this information in P2’s record. b. P2 aspires to travel outside of Minnesota. P2’s CSSP states, “(P2) hopes, dreams, and aspires to… travel outside of Minnesota.” Additionally, P2’s CSSP states, “(P2) would like to buy a new computer for himself/herself through PCs for People.” The license holder failed to provide services in response to P2’s identified needs, interests, preferences, and desired outcomes as specified in P2’s support plan. Corrective Action Ordered: Within 30 days of receiving this order, you must update P2’s record to reflect the information listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.62, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. P1’s IAPP documented that P1 was not susceptible to abuse; however, this assessment was not consistent with information documented and reviewed elsewhere in P1’s record. P1’s CSSP documents that P1 has a history of suicidal ideation, presents a risk of developing a dependency on opioids, and is at risk for self-harm. The license holder failed to include an individualized assessment of P1’s susceptibility of abuse according to Minnesota Statutes, section 626.557. b. P2’s IAPP documented that P2 was not susceptible to abuse or at risk of abusing other vulnerable adults; however, this assessment was not consistent with information documented and reviewed elsewhere in P2’s record. P2’s CSSP documented that P2 has a history of abusing others. The license holder failed to include an individualized assessment of P2’s susceptibility of abuse according to Minnesota Statutes, section 626.577. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the IAPPs for P1 and P2 to meet the requirements of this subdivision and submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services. a. The license holder failed to complete assessments for P1 and P2 which produced information about the persons that described P1 and P2’s overall strengths, functional skills and abilities, and behaviors or symptoms.
b. In a document titled, “45 Day Meeting Summary” dated August 17, 2022, the license holder documented that there was no discussion of technology used to support P2. The license holder failed to include a discussion of how technology might be used to meet P2’s desired outcomes as part of the 45-day planning meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must: · discuss with P2 and P2’s team how technology might be used to meet P2’s desired outcomes. You must also include a summary of this discussion in P2’s support plan addendum and submit this to your licensor; and · review and revise P1 and P2’s assessments to reflect their overall strengths, functional skills and abilities, and behaviors or symptoms and submit this to your licensor. On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), 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. The license holder failed to document the following information in P1 and P2’s current supports and methods for current outcomes: · the measurable and observable criteria for identifying when the desired outcome had been achieved; and · the date by which progress towards accomplishing the outcomes would be reviewed and evaluated. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the service outcomes and supports listed above for P1 and P2 and submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not inform the case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation as required. a. P1’s services were initiated on September 7, 2022. The license holder failed to inform P1’s case manager of the policies and procedures affecting a person’s rights under 245D.04, and provide copies of those policies and procedures within five working days of service initiation. The license holder provided P1’s case manager with these policies on September 22, 2022. b. P2’s services were initiated on June 17, 2022. The license holder failed to inform P2’s case manager of the policies and procedures affecting a person’s rights under 245D.04 and provide copies of those policies and procedures within five working days of service initiation. The license holder provided P2’s case manager with these policies on June 28, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2) the license holder did not meet the requirements for positive support strategies and person-centered planning. The license holder maintained documents in P1 and P2’s records titled, “Positive Support Strategies.” The license holder failed to incorporate positive support strategies in writing into an existing treatment, service, or other individual plan required of the license holder. While P1 and P2 each had the documents titled, “Positive Support Strategies” in their record, three of the four strategies for P1 and P2 were identical.
Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P1 and P2 whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of two 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 the following orientation training within 60 days of hire: · 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 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. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a training curriculum to your licensor for approval. Within 60 days of receiving this order, you must train all staff on the above mentioned topics and submit evidence of this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (f). Violation: For two staff whose records were reviewed (SP1 and SP2), the license holder did not meet requirements for orientation to individual service recipient needs as required. The license holder failed to provide training to SP1 and SP2 on mental health crisis response, de-escalation techniques, and suicide intervention when providing direct support to a person with a serious mental illness. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a training curriculum for the above mentioned topic to your licensor for approval. Within 60 days of receiving this order, you must train all staff who provide direct support to persons served with serious mental illness on the above mentioned topic and submit evidence of this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a) and (b). Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain personnel records as required. The license holder failed to document the following in SP1’s personnel record: · the number of hours per subject area, specifically the training on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities in SP1’s training record; and · the date sufficient to determine SP1’s date of first supervised contact with person served and SP1’s first unsupervised direct contact with person served. Corrective Action Ordered: 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at lacey.l.walsvik@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: Lacey Walsvik 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 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 Lacey Walsvik at 651-431-3667 as soon as possible. Christala Culhane, Supervisor Licensing Division Office of Inspector General
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