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May 19, 2023 Asha Aden Mohamed, Authorized Agent Shifaa Care Inc. 8525 Edinbrook Xing, Ste 103B Brooklyn Park, Minnesota 55443 License Number: 1106926 (245D – HCBS) CORRECTION ORDER Dear Asha Aden Mohamed: On April 26, 2023, a licensing review of Shifaa Care Inc, located at 8525 Edinbrook Xing, Suite 103B, Brooklyn Park, 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. Program Coordination, Evaluation, and Oversight Violations 1. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements of program coordination, evaluation and oversight. a. The license holder failed to ensure that the designated coordinator (SPX), provided supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s CSSP and CSSP 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 CSSP and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired 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. b. The license holder failed to ensure that the designated managers (SPX) provided program management and oversight of the services provided by the license holder that include: · 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; · evaluation of satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071 and ensuring and protecting each person’s rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a, and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations 2 through 13 for the designated coordinator and designated manager failure to provide the above stated requirements. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a written plan detailing how you will ensure that the designated coordinators and designated manager perform the required duties, as identified in these subdivisions, to maintain compliance across the program. You must submit this written plan to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. Service Recipient Violations 2. Citation: Minnesota Statutes, section 245A.65, subdivision X Violation: For three of four persons whose records were reviewed (P1, P3, and P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. 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, the license holder maintained an IAPP in P1’s record dated January 12, 2022, the date P1’s services were initiated; however, the document contained another person’s name throughout the document. DHS licensors were unable to determine if the IAPP developed on January 12, 2022 was an individualized assessment of P1’s susceptibility to abuse by others and P1’s risk of abusing other adults, since another person’s name was used throughout the document. The license holder later developed an IAPP for P1 that did not include another person’s name on March 10, 2022. For P1, the license holder failed to review P1’s IAPP on an annual basis with P1, P1’s case manager and members of P1’s interdisciplinary team. The license holder has not reviewed P1’s IAPP since it was developed on March 10, 2022.
b. For 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 adults. P3’s IAPP dated July 20, 2022, indicated P3 was not at risk of any type of abuse. This was inconsistent with other information in P3’s support plan addendum. c. For P4, the license holder failed to include an individualized assessment of P4’s susceptibility to abuse by others and the person’s risk of abusing other adults. P4’s IAPP dated February 15, 2023, indicated P4 was not as risk of any type of abuse. This was inconsistent with other information in P4’s support plan addendum. Corrective Action Ordered: Within 60 days, you must: · review and revise the IAPPs for P1, P3 and P4 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 and P4’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 P4, and evidence the IAPPs have been reviewed by the person and the person’s case manager to your licensor. On an ongoing basis, you must maintain compliance as required. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not provide the service recipient rights as required. The license holder failed to provide P1 and P4 a written notice that identified the service recipient rights, and an explanation of those rights annually in 2023. · The license holder last provided P1 with a copy on January 12, 2022. · The license holder last provided P4 with a copy on January 7, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 and P4 with a written notice that identifies the service recipient rights and maintain documentation of the person’s receipt of a copy and explanation of these rights. On an ongoing basis you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For four persons whose records were reviewed (P1- P4), the license holder did not maintain documentation on how the person’s health needs would be met. a. The license holder maintained a document titled “Coordinated Services and Support Plan (CSSP) Addendum – Basic Support Services” for P1. The document indicated the license holder was not assigned responsibility for meeting P1’s health needs; however, P1’s support plan completed by the case manager on October 11, 2022 indicated that individualized home supports staff will assist P1 with medication management. The license holder failed to maintain documentation on how P1’s health needs will be met, including a description of the procedures the license holder will follow in order to provide medication setup, assistance, or administration. b. The license holder maintained a document titled “Coordinated Services and Support Plan (CSSP) Addendum – Basic Support Services” for P2. The document indicated the license holder was not assigned responsibility for meeting P2’s health needs, however, time sheets completed by P2’s staff person providing night supervision services indicate that the staff person was assisting with the CPAP (continuous positive airway pressure) machine and was positioning the CPAP mask on P2’s face at night. The license holder failed to maintain documentation on how P2’s health needs will be met, including a description of how to use medical equipment and devices safely and correctly according to written instructions from a licensed health professional. c. The license holder maintained a document titled “Coordinated Services and Support Plan (CSSP) Addendum – Intensive Support Services” for P3. The document indicated the license holder was not assigned responsibility for meeting P3’s health needs, however, P3’s Intensive Support Self-Management Assessment included information that was contradictory to this and indicated the license holder assisted P3 with medication assistance/reminders, and assistance with scheduling medical appointments and communicating with medical providers. The license holder failed to maintain documentation on how P4’s health needs will be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health services appointments and to provide medication assistance. c. The license holder maintained a document titled “Coordinated Services and Support Plan (CSSP) Addendum – Intensive Support Services” for P4. The document indicated the license holder was not assigned responsibility for meeting P4’s health needs; however, P4’s Intensive Support Self-Management Assessment included information that was contradictory to this and indicated the license holder assisted P4 with medication assistance and scheduling dental/medical appointments. The license holder failed to maintain documentation on how P4’s health needs will be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health services appointments Corrective Action Ordered: Within 30 days of receiving this order, you must document how P1-P4’s health needs will be met consistently in each person’s support plan addendum. On an ongoing basis you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivisions 2. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not meet service planning requirements as required. a. P1’s support plan addendum dated March 10, 2022, required annual service planning and support team meetings and annual progress reports. The license holder failed to hold a service planning and support team meeting or provide a progress report for P1 annually in 2023. b. The license holder failed to review P2’s preliminary support plan addendum within 60 calendar days of service initiation 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 the services. At the time of the licensing review, P2’s preliminary support plan addendum had not yet been reviewed. c. The license holder provided multiple services to P4. The license holder failed to identify how services are provided for each service P4 receives, when services are provided, and the person responsible for oversight and coordination of the services. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review P2’s preliminary support plan addendum to ensure the above-mentioned information is documented in P2’s support plan addendum; · hold a service planning and support team meeting for P1 with P1, P1’s case manager, and members of P1’s support team. You must document the date of the meeting, what was discussed at the meeting and the names of the individuals who attended this meeting and maintain the documentation in P1’s record; · provide a written report regarding P1’s progress or status to P1 and to P1’s support team. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P3), the license holder did not meet service planning requirements for an intensive service, as required. P3’s services were initiated on July 23, 2021. The license holder failed to hold an initial service planning meeting with P3, P3’s case manager and other members of the support team before providing 45 days of service or within 60 calendar days of service initiation, whichever is shorter. The license holder later held a service planning meeting on July 5, 2022; where the license holder determined the required information. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not develop supports and outcomes as required. a. For P3, the license holder completed a document titled, “Supports and Outcome Methods for Intensive Support Services.” However, the information contained on the documents failed to meet the requirements of this section. b. For P3 and P4, the license holder failed to, within ten working days of the 45-day planning meeting, document the supports and methods to be implemented to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being, including: · the methods or actions that will be used to support the person and 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 and materials required; and o techniques that were consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop the above-mentioned information for P3 and P4; · maintain documentation in P3 and P4’s record; and · submit a copy of the outcome(s) you develop for P3 and P4 to your licensor. On an ongoing basis, you must develop supports and methods as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not meet service plan review and evaluation as required. a. P3’s coordinated services and support plan completed by P3’s case manager on March 4, 2022, required the license holder to provide quarterly progress reports. The license holder failed to provide progress for P3 on a quarterly basis. The license holder completed a progress report for P3 on July 5, 2022. Additionally, although the license holder completed a progress report for P3 on July 5, 2022, the license holder did not develop an outcome for P3 according to the requirements in 245D.071, subdivision 4 and did not collect data on an outcome for P3; therefore, the license holder failed to provide a progress report that summarized the person's progress towards achieving an identified outcome as required. b. The license holder met with P4 on February 15, 2023; however, the license holder failed to, at least once per year, complete the following: · meet with P4’s case manager and other people as identified by P4, to participate in the ongoing review and development of the service plan and the methods used to support the person and accomplish outcomes identified in subdivision 3 and 4; · meet with P4’s case manager and other people as identified by P4 and participate in service plan review meetings following stated timelines established in P4’s support plan or support plan addendum; · discuss how technology might be used to meet P4’s desired outcomes and include a summary of this discussion in P4’s support plan addendum; and · summarize P4’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of support and methods identified in section 245D.071, subdivision 4 in a report available at the time of the progress review meeting. Corrective Action Ordered: Within 60 days of this order, you must: · meet with P4 and P4’s case manager, and participate in a service plan review meeting, to determine whether changes are needed to the service plan based on the assessment information, the license holder’s evaluation of progress towards accomplishing outcomes, or other information provided by the support team or expanded support team; and · follow the corrective action in violation 7 regarding P3. On an ongoing basis you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain service recipient records as required. a. The license holder failed to maintain the following for P1: · copies of written reports regarding P4’s status when requested according to section 245D.07, subdivision 3; and · progress or daily log notes that are recorded by the program. b. The license holder failed to maintain progress or daily log notes that are recorded by the program for P2 and P3. c. The license holder failed to maintain the following for P4: · the persons current support plan; · copies of written reports regarding P4’s status when requested according to section 245D.07, subdivision 3; · progress review reports as required under section 245D.071, subdivision 5; and · progress or daily log notes that are recorded by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining progress notes for P1-P4. On an ongoing basis you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P1) the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. For P1, the license holder failed to inform the person’s case manager and provide copies of the policies and procedures that affect a person’s rights under section 245D.04 within five working days of service initiation. P1’s services were initiated on January 12, 2022 and the case manager was provided the policies on January 26, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required. Staffing Standards Violations 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three of four staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide orientation training as required. SP1 was hired on October 4, 2021, SP2 was hired on June 14, 2021, and SP3 was hired on November 28, 2022. The license holder failed to provide SP1, SP2 and SP3 with an orientation to the following 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 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 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, 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 SP3 with an orientation to the training requirements listed above; · complete the corrective action required in citation 12 for SP1 and SP2; and · maintain documentation of this training as required in section 245D.095, subdivision 5; On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5 Violation: for two persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual training as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP1 and SP2 with annual training in 2022 on the following topics: · 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; · 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 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, 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 and SP2 with training on the required topics listed above; and · maintain documentation of this training as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not maintain personnel records as required. The license holder failed to maintain personnel records for SP1, SP2 and SP3 that maintained documentation of the following: · SP3’s first date of supervised direct contact with a person served by the program; and · SP1, SP2’s and SP3’s date of first unsupervised direct contact with a person served by the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Program Policies and Procedures 14. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not establish and maintain policies and procedures as required in this chapter. While the license holder did develop a policy titled “Emergency Use of Manual Restraints Policy,” the license holder failed to include the following requirements in that policy: · develop, document, and implement a policy that promoted service recipient rights and protected health and safety during the emergency use of manual restraint; · include a description of the types of manual restraints the license holder allows staff to use on an emergency basis; and · instructions for safe and correct implementation of the allowed manual restraint procedures as required in section 245D.061, subdivision 9. Corrective Action Ordered: Within 15 days of receiving this order, you must: · revise your emergency use of manual restraints policy to implement the above stated requirements; and · submit the revised policy to your licensor. Additionally, within 30 days of receiving this order, you must: · provide notice, in writing, to all persons receiving services under this license, their legal representatives, if any, and case managers of your revised policy on the emergency use of manual restraint as required in part 9544.0080, subparts 1 and 2; · obtain written acknowledgement from the person, or the person’s legal representative, that the person receiving services has been notified of your policy regarding the emergency use of manual restraints, as required in part 9544.0080, subpart 1; · inform all employees providing services under this license of the revisions and provide training on implementation of the revised policy and procedures. 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 Elizabeth.Schiefelbein@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: Liz Schiefelbein 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 me as soon as possible. Liz Schiefelbein, Senior Licensor Licensing Division Office of Inspector General 651-431-2738
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