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May 8, 2023 Maslah Warsame, Authorized Agent CarePlus Healthcare Services LLC 2021 East Hennepin Avenue Suite 100-9 Minneapolis, Minnesota 55413 License Number: 1107886 (245D – HCBS) CORRECTION ORDER Dear Maslah Warsame, On March 29, 2023, a licensing review of CarePlus Healthcare Services LLC, located at 2021 East Hennepin Avenue, Minneapolis, 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 1. Violation: For one of three persons whose record was reviewed (P2), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required.
P2’s services were initiated on December 30, 2022. The license holder failed to provide P2 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults with 24 hours of admission.
Corrective Action Ordered: Within 30 days of receiving this order, you must provide an orientation to the internal and external reporting procedures to P2. In addition, you must maintain documentation of this orientation as required in section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and section 626.557, subdivision 14. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder maintained an IAPP for P1 dated January 10, 2023. The license holder documented that P1 was susceptible to physical abuse, however, the license holder failed to include a statement of measures that would be taken to minimize the risk of physical abuse to P1. Additionally, the license holder maintained documentation of P1’s “Coordinated Services and Supports Plan (CSSP).” P1’s CSSP stated P1 “experiences impulsivity and may engage in high-risk behaviors four or more times a week” and that P1 “experiences difficulties with managing paperwork and finances.” The license holder failed to contain this information in the individualized assessment of: · P1's susceptibility to abuse by other individuals, including other vulnerable adults; and · P1's risk of abusing other vulnerable adults. b. The license holder failed to develop an IAPP for P2 as part of the initial individual program plan. Services were initiated for P2 on December 30, 2022, however, the license holder had not developed an IAPP for P2 at the time of the licensing review. Corrective Action Ordered: Immediately, you must develop an IAPP for P2. Within 30 days of receiving this order, you must: · develop an IAPP for P1 that includes accurate individualized assessments of the person’s susceptibility to abuse and risk of abusing others; · review P1 and P2 IAPPs with the person’s interdisciplinary teams and document the review of the IAPP in the person’s record; · audit all IAPPs for all persons served and ensure that IAPPs meet the requirements as specified in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and section 626.557, subdivision 14; and · based on the results of the audit, develop a detailed plan describing how you will come into compliance with these requirements within 60 calendar days of receiving this order. On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide P2 a written notice that identified the service recipient rights and explanation of those rights at service initiation. Corrective Action Ordered: Immediately, you must provide P2 a written notice that identifies the service recipient rights and an explanation of those rights. In addition, you must maintain documentation of this orientation as required in section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (c). Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for basic support services. The license holder failed to review and revise as needed P1’s preliminary support plan addendum within 60 calendar days of service initiation. P1 initiated services on January 14, 2023 and did not have a completed 60 day on or before March 14, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise as needed P1’s preliminary support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not complete assessments and initial service planning for intensive support services as required. The license holder failed to: · complete assessments for P2 and P3 which produced information about the persons that describes P2 and P3’s overall strengths and functional skills and abilities; and · meet with P2 and P2’s case manager within 45 days of service initiation to determine: o the scope of the services to be provided to support the person's daily needs and activities; o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; o the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; o whether the current service setting is the most integrated setting available and appropriate for the person; o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and o a discussion of how technology might be used to meet the person's desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update the assessments for P2 and P3 to produce information about the persons that describes P2 and P3’s overall strengths and functional skills and abilities; and · meet with P2 and P2’s case manager to determine: o the scope of the services to be provided to support the person's daily needs and activities; o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; o the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; o whether the current service setting is the most integrated setting available and appropriate for the person; o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and o a discussion of how technology might be used to meet the person's desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include: § a statement regarding any decision that is made regarding the use of technology; and § a description of any further research that needs to be completed before a decision regarding the use of technology can be made. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not document service outcomes and supports for intensive support services as required. The license holder failed to document the following supports and methods to be implemented to support P2 and P3 and accomplish outcomes: · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; and · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated. Additionally, the license holder failed to document the date that P2 and P3’s service outcomes and supports were developed; therefore, it was unable to be determined if the license holder developed a service plan that documented the service outcomes and supports within ten working days of the 45-day planning meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan that documents the service outcomes and supports, including the documentation detailed above for P2 and P3; and · submit the documentation to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress notes or daily log notes that were recorded by the program in P1-P3’s service recipient records. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three of three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide and ensure completion of orientation as required. The license holder failed to provide orientation training to SP1-SP3 in the following areas within 60 days of hire: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied 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 · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1-SP3 orientation training as detailed above; · document the training according to Minnesota Statutes, section 245D.095, subdivision 5; and · submit documentation of the completed training to your licensor, including: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. 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 kristopher.oberg@state.mn.us or 2. If you are unable to submit corrective action ordered securely through email, you can mail the information below: Commissioner, Department of Human Services ATTN: Kristopher Oberg 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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 Kris Oberg at 651-431-6589 as soon as possible. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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