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May 11, 2023 Ahmed Muhumud, Authorized Agent Preferred Choice Home Care 2626 E 82nd Street Suite 330 Bloomington, MN 55425 License Number: 1103241 (245D – HCBS) CORRECTION ORDER Dear Ahmed Muhumud: On February 21, 2023, a licensing review of Preferred Choice Home Care located at 2626 E 82nd Street, Suite 330, Bloomington, 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 1. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not provide an orientation to the internal and external reporting procedures of alleged and suspected maltreatment as required. a. P1 was admitted on May 23, 2022. The license holder failed to provide orientation to the internal and external reporting procedures of alleged and suspected maltreatment to P1’s legal representative within 24 hours of admission. b. P2 was admitted on January 8, 2022. The license holder failed to provide orientation to internal and external reporting procedures of alleged and suspected maltreatment to P2 within 24 hours of admission. Corrective Action Ordered: Within 60 days of receiving this order you must: · provide orientation to the internal and external reporting procedures of alleged and suspected maltreatment to P1 and P1’s legal representative; · provide orientation to the internal and external reporting procedures of alleged and suspected maltreatment to P2; · submit documentation to your licensor that P1, P1’s legal representative, and P2 received this information; · complete an audit of all service recipient records receiving services licensed under this chapter to ensure each person was provided with orientation to your internal and external reporting procedures or alleged or suspected maltreatment of vulnerable adults; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet requirements for an individual abuse prevention plan (IAPP) as required. a. The license holder failed to develop an IAPP for P1 as part of the initial service plan. P1’s services were initiated on May 23, 2022. An IAPP had not been developed at the time of review. b. The license holder failed to develop an IAPP for P2 as part of the initial service plan. P2’s services were initiated on January 8, 2022. An IAPP had not been developed at the time of review. Corrective Action Ordered: Within 60 days of receiving this order you must · develop P1 and P2’s IAPP to include an individualized assessment of each person’s susceptibility to: o abuse by other individuals; o the person’s risk of abusing other vulnerable adults; and o statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. · submit documentation to your licensor that P1 and P2’s IAPP was developed; and · complete an audit of all service recipient records receiving services licensed under this chapter to ensure an IAPP was developed for each person as required. · Maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the service recipient rights as required. a. P1’s service initiation was on May 23, 2022. The license holder failed to provide P1 and P1’s legal representative with a written notice that identifies the service recipient rights and an explanation of those rights within five working days of service initiation. b. P2’s services were initiated on January 8, 2022. The license holder failed to provide P2 with a written notice that identifies the service recipient rights and an explanation of those rights within five working days of service initiation. Additionally, the license holder failed to provide written notice of service recipient rights in 2023. Corrective Action Ordered: Within 60 days of receiving this order you must: · provide P1 and P1’s legal representative, and P2 with written notice that identified the service recipient’s rights; · You are also ordered to submit documentation that P1 and P2’s legal representative received this information to your licensor; · complete an audit of all service recipient records receiving services licensed under this chapter; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2 and 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for basic support services as required. The license holder failed to do the following as a provision of respite services for P1: · complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation; · review and revise as needed the 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 within 60 calendar days of service initiation of respite services; · participate in service planning and support team meetings for the person following stated timeline established in the person’s support plan or as requested by the person or the person’s legal representative, the support team or the expanded support team; and · provide written reports regarding the person’s progress or status as requested by the person, the person’s legal representative, or case manager.
Corrective Action Ordered: Within 60 days of receiving this order you must complete a support plan addendum for P1 based on the support plan that includes how, when and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services. You must submit this to your licensor. 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 record were reviewed (P1 and P2), the license holder did not meet service planning and delivery requirements for an intensive service as required. Regarding P1 and P2 the license holder failed to: · complete assessments that included information about the person that described the person’s overall strengths, function skills and abilities and behaviors or symptoms; and · meet with the person, the person’s legal representative, case manager and other members of the expanded support team within 45-days of service initiation. Additionally, at this meeting the license holder failed to determine: o the scope of the services to be provided to support the person’s daily needs and activities; o the persons desired outcomes and the supports necessary to accomplish the persons’ desired outcomes; o the person’s preference 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 opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; o opportunities for community access, participation, and inclusion in preferred community activities; o opportunities to develop and strengthen personal relationships with other persons of the persons choice in the community; 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 the following: § a statement regarding any decision that is made regarding the use technology; and § a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 60 days of receiving this order, you must complete assessments for P1 and P2 that include information about the person that described the person’s overall strengths, function skills and abilities and behaviors or symptoms. You must submit these to your licensor. Additionally, within 60 days of receiving this order you must meet with P1 and P2, their legal representatives and case managers and other members of the support team or expanded support team to determine the above information. 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 record was reviewed (P1 and P2), the license holder did not develop service outcomes and supports based on the assessments as required. The license holder failed to document the following information in P1 and P2’s current supports and methods for current outcomes: · 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 services supports are provided, any equipment and materials required; and 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 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 a service plan that documents the service outcomes and supports listed above for P1 and P2. You are also ordered to submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose records were reviewed (P2), the license holder did not meet the requirements for service plan review and evaluation as required. 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. P2’s services were initiated on January 8, 2022. The license holder failed to meet with P2, P2’s case manager and other members of the support team at least annually. The license holder had not held an annual meeting at the time of this review. Corrective Action Ordered: Within 60 days of receiving this correction order, you must meet with P2 and P2’s support team for a service planning and support team meeting. On an ongoing basis, you must maintain compliance as required in this subdivision 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain a service recipient record as required. a. Regarding P1 and P2 the license holder failed to maintain the progress or daily log notes that are recorded by the program. b. Regarding P1 and P2 the license holder failed to maintain a signed statement authorizing the license holder to act in a medical emergency when the person’s legal representative, if any, cannot be reached or is delayed in arriving. Corrective Action Ordered: Within 60 days of receiving this order, you must develop a plan of how you will come into compliance to maintain daily progress notes and submit this to your licensor. On an ongoing basis, you must maintain the above-mentioned information in P1 and P2’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not inform the person and 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 May 23, 2022. The license holder failed to inform P1, P1’s legal representative and P1’s 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. b. P2’s services were initiated on January 8, 2022. The license holder failed to inform P2’s and P2’s 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. Corrective Action Ordered: Within 60 days of receiving this order, you must: · inform P1, P1’s legal representative and case manager of the policies and procedures affecting a person’s rights under section 245D.04, and provide copies of those policies and procedures; · inform P2’s and P2’s case manager of the policies and procedures affecting a person’s rights under section 245D.04, and provide copies of those policies and procedures; · submit documentation to your licensor that P1, P1’s case manager, P2’s legal representative and P2’s case manager received this information; · complete an audit of all service recipient records receiving services licensed under this chapter to ensure these policies and procedures have been provided and meet the requirements of this subdivision; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules, part 9544.0030, subpart 1 Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate with P1 and P2, at least every six months, if any positive support strategies used needed changes, and, if so make appropriate changes. Corrective Action Ordered: Within 60 days of receiving this order, you must evaluate with P1 and P2 whether the identified positive support strategies currently meet the standards in Minnesota Rules, part 9544.0030, 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. Additionally, you must maintain documentation of compliance with these requirements as required in Minnesota Rules, part 9544.0100. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, part 9544.0080, subparts 1 and 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide notice of their policy on the emergency use of manual restraint as required. a. P1’s services were initiated on May 23, 2022. The license holder failed to provide P1 and P1’s legal representative with a written notice on the license holder’s policy on the emergency use of manual restraint that informed the person of the person’s rights under this chapter and Minnesota Statutes, section 245D.04. Additionally, the license holder failed to obtain a written acknowledgment from the person, or the person’s legal representative, that the person receiving services had been notified. b. P2’s services were initiated on January 8, 2022. The license holder failed to provide P2 written notice on the license holder’s policy on the emergency use of manual restraint that informed the person of the person’s rights under this chapter and Minnesota Statutes, section 245D.04. Additionally, the license holder failed to obtain a written acknowledgment from the person, that the person receiving services had been notified. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide P1 and P1’s legal representative written notice of your policy on the emergency use of manual restraint; · obtain a written acknowledgment from P1 or P1’s legal representative that the person receiving services has been notified; · provide P2 written notice of your policy on the emergency use of manual restraint; · obtain a written acknowledgment from P2 that they have been notified. · complete an audit of all service recipient records receiving services licensed under this chapter to ensure each person was provided with a written notice on your policy on the emergency use of manual restraint that meets the requirements of this subpart; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of three staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation training as required. a. Regarding SP2 hired on March 1, 2020, and SP3 hired on November 30, 2021, the license holder failed to provide the following orientation training within 60 days of hire: · the job description and how to complete specific job functions including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures including: o grievance policy o service suspension policy o service termination policy; and o prohibition on drug and alcohol use policy; · 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; · 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 program abuse prevention plan according to the requirements in 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 provide SP2 and SP3 with the above mentioned training. On an ongoing basis, you must provide orientation training as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation training as required. a. SP2 had unsupervised direct contact with a person served by the program on March 1, 2020. The license holder failed to review and provide instruction on the following as it relates to the responsibilities assigned to the license holder: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan. b. SP3 had unsupervised contact with a person served by the program on December 4, 2021. The license holder failed to review and provide instruction on the following as it relates to the responsibilities assigned to the license holder · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan. Corrective Action: Within 60 days of receiving this order, you must provide SP2 and SP3 with the above training. You must submit documentation of this training as required in 245D.095, subdivision 5, paragraph (a) clause (2) to your licensor. On an ongoing basis, you must provide annual training as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 5 Violation: For two staff persons whose record was reviewed (SP2 and SP3), the license holder did not provide annual training as required. The license holder failed to provide SP2 with the following training in 2021 and 2022 and SP 3 with the following training in 2022: · data privacy requirements according to section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996(HIPPA), 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; · sections 254A.65, 245A.66, 626.556, and 626.558, governing maltreatment reporting and serviced planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · the principles of person-centered planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff; · 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 the 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; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent and bodily autonomy of people with disabilities; and · basic first aid. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP2 and SP3 with the above annual training. You must submit documentation of this training as required in 245D.095, subdivision 5, paragraph (a) clause (2) to your licensor. On an ongoing basis, you must provide annual training as required in this subdivision. 15. 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 persons as required. The designated coordinated identified by the license holder (SP1) failed to provide supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s service and support plan and the service and support plan addendum; · taking the necessary action to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the support plan and the 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 measureable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. The failure to provide coordination and evaluation of individual service delivery is evidenced in citations 1 through 13. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person other than SP1, to be appointed as the designated coordinator, who is responsible for delivery and evaluation of services provided by the license holder; and · submit the name, contact information and qualifications of the person(s) you have designated and have ensured is competent to perform the duties of the designated coordinator as required in this section. 16. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not ensure that the designated managerial staff persons provided program management and oversight of the services provided as required. The designated manager identified by the license holder (SP1) failed to provide program management and oversight of the services provided by being responsible for the following: · maintaining a current understanding of the license requirements sufficient to ensure compliance throughout the program; · ensuring the duties of the designated coordinator are fulfilled; and · ensuring staff competency requirements are met. The failure to provide program management and oversight of services provided is evidenced in citations 1 through 13. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person, other than SP1, to be appointed as the designated manager, who is responsible for delivery and evaluation of services provided by the license holder; · submit the name, contact information and qualifications of the persons(s) you have designated and ensured is competent to perform the duties of the designated manager as required in this section. 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 nicole.m.riley@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: Nicole Riley 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 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 Nicole Riley, Senior Licensor, at 651-431-3657, as soon as possible. Christala Culhane, Human Services Licensor Licensing Division Office of Inspector General
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