|
May 17, 2023 Iyabo Oluwakemi Adeyemi, Authorized Agent Certified Home Care 4080 W Broadway Ave #140A Robbinsdale, MN 55422 License Number: 1081849 (245D - HCBS) CORRECTION ORDER Dear Iyabo Oluwakemi Adeyemi: On May 2, 2023, a licensing review of Certified Home Care, located at 4080 West Broadway Avenue, Suite 140A, Robbinsdale, 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 2, paragraph (b), clause (1). Violation: For three of three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) 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. a. For P1-P3, the license holder failed to include an individualized assessment of the person’s susceptibility to abuse by others and the person’s risk of abusing other vulnerable adults. · P1’s IAPP indicated P1 was not susceptible to any type of abuse and was not at risk of abusing other vulnerable adults. This information was inconsistent to other information in P1’s record. P1’s community support plan dated January 12, 2023 stated that P1 had behaviors that put themselves and others at risk. The community support plan stated that P1 may have self-injurious behaviors and may become verbally aggressive and physically aggressive. · P2’s IAPP indicated that P2 was not susceptible to any type of abuse and was not at risk of abusing other vulnerable adults. This information was inconsistent with other information in P2’s record that indicated P2 was at risk of self-abuse. P2’s coordinated services and supports plan, dated July 5, 2021, stated that P2 isolated themselves, was often overwhelmed, and spent most days in bed worrying. · P3’s IAPP indicated that P3 was not susceptible to any type of abuse and was not at risk of abusing other vulnerable adults. This information was inconsistent with other information in P3’s record that indicated P3 was susceptible to financial abuse and self-abuse. P3’s coordinated services and supports plan, dated December 14, 2022, stated that P3 has had several cell phones stolen by acquaintances and that P3 has given their money away to others when they ask. b. The license holder failed to review P2’s IAPP on an annual basis with P2’s interdisciplinary team. The license holder developed P2’s IAPP on August 31, 2021. The license holder has not reviewed P2’s IAPP since it was developed. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 26, 2018. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise the IAPPs for P1-P3 to include: o an assessment of the person's susceptibility to abuse by other individuals, including other vulnerable adults and 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 within the scope of each service the person receives. · review P1-P3’s IAPPs with the person, the person’s legal representative, as applicable, and the person’s case manager. You must document this review; and · submit the revised IAPPs for P1-P3, 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 three persons whose records were reviewed (P1-P3), the license holder did not provide the person, or their legal representative, a written notice that identified the service recipient rights and an explanation of those rights as required. a. The written notice provided to P1’s legal representative, and to P2-P3, failed to include the right of access to the person's personal possessions at any time, including financial resources. b. The license holder failed to provide the written notice that identified the service recipient rights annually to P2. The license holder provided P2 with a written notice on August 31, 2021. The license holder has not provided P2 with a copy since that date. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 26, 2018. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1’s legal representative, P2, and P3 with an explanation and written notice that identifies the service recipient rights in subdivisions 2, and 3, ensuring this explanation and written notice includes the right to access the person’s personal possessions at any time, including financial resources; · maintain documentation of P1’s legal representative, P2, and P3’s receipt of a copy and explanation of these rights, including a copy of the written notice that was provided; · audit all service recipient records receiving services under this license to ensure the following: o each service recipient and/or their legal representative, if applicable, has received a written notice that identifies the service recipient rights in subdivisions 2 and 3, within the previous 12 months; o the written notice provided to each service recipient and/or their legal representative, if applicable, identified the right to access the person’s personal possessions at any time, including financial resources; · if any service recipient, or their legal representative, if applicable, have not received these rights within the previous 12 months, or received a written notice that failed to include the right to access the person’s personal possessions at any time, including financial resources, you must provide these rights as required and maintain documentation of their receipt of these rights, including a copy of the written notice that was provided; and · maintain documentation of the results of this audit that includes notation of action taken to come into compliance and when the action occurred. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P1-P2), 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 maintained a document in both P1 and P2’s record titled “Coordinated Service and Support Plan (CSSP) Addendum” that was developed by the license holder. The license holder documented the same information in both P1 and P2’s support plan regarding their needs, interests, preferences, and how services would be provided. The license holder failed to provide person-centered service planning when the support plans failed to include P1 and P2’s identified needs, interests, and preferences as unique individuals. Corrective Action Required: Within 30 days of receiving this order, you must: · review and revise P1 and P2’s support plan addendums to include information about how the person’s services will be provided in a manner that supports the identified needs, interests, and preferences as unique individuals; and · complete an audit the records of all persons served by your program to ensure each person’s support plan addendum includes the information listed above. Within 60 days of receiving this order, you must: · based on the results of your audit, review and revise the support plan addendum for any person you are serving whose support plan addendum does not have the above-mentioned information; · train all staff who work with any person whose support plan addendum has been updated as a result of the audit on the changes to the person’s support plan addendum. You must document the review of the support plan addendum in the staff person’s record; · submit the updated support plan addendums for P1 and P2 to your licensor; and · submit the results of your audit and the dates you updated the support plan addendums for any person identified in your audit whose plan did not include the above-mentioned information to your licensor. On an ongoing basis, you must maintain compliance as required. 4. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not incorporate and evaluate positive support strategies as required. The holder failed to develop positive support strategies for P1-P3 and incorporate the positive support strategies in writing to an existing treatment, service, or other individual plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · For P1-P3, assess the person’s strengths, needs, and preferences to identify and develop positive support strategies for the person. You must incorporate the positive support strategies for P1-P3 in writing to an existing treatment, service, or other individual plan for each person; and · submit positive support strategies developed for P1 through P3 to your licensor. Additionally, at least every six months, you must evaluate with the person the identified positive support strategies, and based upon the results of that evaluation, determine whether changes are needed in the positives support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in these subparts. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For three person whose record was reviewed (P1-P3), the license holder did not provide written or electronic copies of policies and procedures as required. a. The license holder failed to inform P1 and P2’s case managers of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; and · emergency use of manual restraints policy. b. The license holder failed to inform P3’s case manager, and provide copies of the following policies and procedures, within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 26, 2018.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the above mentioned policies and procedures to P1-P3’s case managers; and · audit all service recipient records for persons receiving services under this license to ensure that all persons or their legal representatives, as applicable, and all persons’ case managers have been informed of and provided copies of the policies and procedures that affect a person’s rights; · for any person or their legal representative, as applicable, or case manager that has not been informed of and provided copies of the policies and procedures that affect a person’s rights, you must provide copies and maintain documentation in the person’s record showing that the policies were provided; and · maintain documentation of the results of this audit that includes notation of action taken to come into compliance and when the action occurred. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 3, item B, subitem (11). Violation: For three persons whose record was reviewed (P1-P3), 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-P3. 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 for all persons receiving services from your program as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinator (SP1) was competent to perform the required duties, including the supervision, support, and evaluation of activities that included: · oversight of the license holder's responsibilities assigned in the person's support plan and the 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 support plan and the service outcomes, including the failure to have an established process in which the designated coordinator determines the competency of the person that has been has delegated the responsibility to directly observe the service delivery activities 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 has been achieved according to the requirements in section 245D.07. The failure to provide program coordination and oversight of the services provided is evidenced in citations 1-6. b. The license holder failed to ensure the designated manager (SP2), was competent to perform the required program management and oversight of the services provided by the license holder, including: · maintaining a current understanding 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 section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the services provided is evidenced in citations 1-6 and 8. Corrective Action Ordered: Within 30 days of receiving this order, you must: · submit documentation to your licensor that the designated coordinator (SP1) has reviewed and acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2; · submit documentation to your licensor that the designated manager (SP2) has acknowledged and understood their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 3; and · follow the corrective action ordered throughout this order and submit evidence of completion as requested. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one of four staff persons whose records were reviewed (SP3), the license holder did not provide annual training as required.
SP3’s date of hire was June 30, 2021. The license holder failed to provide the following annual training to SP3 in 2022. At the time of the licensing review, SP3 had not yet received this training. · 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 right, 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; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 26, 2018. Corrective Action Required: Within 30 days of receiving this order, you must: · develop and maintain a training curriculum for each training topic required to be provided to staff persons; · provide SP3 with the training identified above and document the training in SP3’s personnel record as required in section 245D.095, subdivision 5; · complete an audit of all staff annual training records to ensure all staff persons have received annual training on all required topics identified above in the previous 12 months; · provide any lapsed training identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; · maintain documentation of the results of this audit that includes notation of action taken to come into compliance and when the action occurred; and · submit evidence showing SP3 received the training identified above to your licensor. On an ongoing basis, you must provide annual training 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
|
