|
April 25, 2023 Samatar Dualeh, Authorized Agent Silver Mountain Home Health Care LLC 1603 Chicago Avenue Minneapolis, Minnesota 55404 License number: 1081219 (245D-HCBS)
NOTICE OF NONCOMPLIANCE AND CORRECTION ORDER Dear Samatar Dualeh: On February 6, 2023, a Correction Order was issued to Silver Mountain Home Health Care LLC located at 1603 Chicago Avenue, Minneapolis, Minnesota, as a result of a licensing review. You were ordered to submit evidence of corrective action taken for violations determined under citations number 3, 5, and 6 within 30 days of receipt of the order. On March 9, 2023, a review of your submissions received on March 6, 2023 was concluded. For citation number 3, 5 and 6 it has been determined that corrective action has not been achieved. As a result, this notice of noncompliance is being issued including an additional citation. Additional materials submitted but not ordered have not been reviewed and will not be addressed in this order. I. CORRECTION ORDER A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that a 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 following a review of submissions required under the February 6, 2023, Correction Order. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 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. License Holder Response: Regarding P2, the license holder was responsible for providing individualized home supports without training and night supervision. The license holder submitted a document entitled “Coordinated Service and Support Plan (CSSP) Addendum – Basic Support Services’ dated February 11, 2023. The license holder documented in this plan that they would assist P1 with socialization, shopping, setting up medical appointments and cueing and reminders of self-care per their preference when providing individualized home supports without training. For night supervision it was documented that the license holder would support P2 during the night that included assistance with fall prevention during trips to the bathroom, toileting assistance and behavior redirection for safety nightly. Regarding P3, the license holder was responsible for providing individualized home supports (IHS) with family training and respite services. The license holder submitted a document entitled “Coordinated Service and Support Plan (CSSP) Addendum – Intensive Support Services” dated February 11, 2023. The license holder documented that they would provide IHS with family training by assisting with recreational activities and assistance after school per P3’s preferences. For respite services, the plan documents that staff will assist with P3’s needs while their primary care giver is absent per P3’s preferences. DHS Response: The license holder failed to include in the plans for P2 and P3 how staff would support P2 and P3 as individual people. P2’s plan stated that staff would assist with socialization, however, the plan does not give any explanation of how staff would assist P2 with socialization. The plan references that staff will provide services in response to P2’s preferences multiple times, however, the license holder failed to identify what P2’s preferences. In regard to night supervision, it says that staff will redirect night walking behavior, but there is no explanation of how staff should respond to this behavior. P3’s states multiple times that services will be provided in response to P3’s needs and preferences; however, the plan does not identify what P3’s needs and preferences are, or how staff will support P3 to meet their needs. In addition, the plan developed by the license holder does not meet the criteria for individualized home support with family training as required in the federal waiver plans for IHS with family training. Corrective Action Ordered: Within 60 days or receipt of this order, you must develop a plan for P2 and P3 that identify P2 and P3’s needs, preferences, and how staff will support P2 and P3 based on those needs and preferences. You must submit a copy of these plans to your licensor. On an ongoing basis, you must maintain compliance with this subdivision. 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. License Holder Response: The license holder submitted P3’s “Coordinated Service Support Plan Addendum – Intensive Support Services.” DHS Response: The license holder failed to submit 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. Corrective Action Ordered: Within 60 days of receipt of this order, you must complete the following assessments for P3 and submit to your licensor: 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. On an ongoing basis, you must maintain compliance 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. License holder’s response: The license holder submitted P3’s Coordinated Service Support Plan (CSSP) Addendum – Intensive Support Services dated February 11, 2023, that included three outcomes. DHS Response: The license holder failed to support P3 to acquire, retain and improve their skills and well-being with implementation of the documented outcomes on P3's Coordinated Service and Support Plan (CSSP) Addendum- Intensive Support Services. In addition, the license holder failed to include 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 60 days of receipt of this order, 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. Additional Citation Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: The license holder did not ensure the delivery and evaluation of services provided were coordinated by the designated staff person and did not ensure the designated managerial staff persons provided program management and oversight as required. a. The designated coordinators identified by the license holder failed to provide supervision, support, and evaluation of the activities that include: · oversight of the license holder’s responsibilities as assigned in the person’s coordinated service support plan and the coordinated service 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 support plan and 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 had been achieved according to the requirements in section 245D.07. The failure to provide supervision, support, and evaluation of the activities listed above is evidenced in the failure to take corrective action for citations 3, 5 and 6. b. The designated managers identified by the license holder failed to provide program management and oversight of the service provided by being responsible for the following: · maintaining a current understating of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable as identified in 256B.04, subdivision 21, paragraph (b); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision (2); and · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 4, 4a, and 5. The failure to provide program management and oversight of the service provided is evidenced in citations 3, 5 and 6. Corrective action ordered: Within 30 days of receiving this order, you must submit the name of the person or persons that you have hired to perform the duties of the designated coordinator and the designated manager. You must verify and document their competence according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3. You must submit the name of the person or persons and a detailed description of how they are qualified to perform the duties of the designated coordinator and designated manager. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 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 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 651-431-6638. Sincerely, Diana Arnzen, Senior Licensor Licensing Division Office of Inspector General
|
