|
June 9, 2023 Fauzia Osman, Authorized Agent Nina Services LLC 12800 Whitewater Drive Suite 100 Minnetonka, Minnesota 55343 License Number: 1107591 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Fauzia Osman: On April 28, 2023, a licensing review of Nina Services LLC, located at 12800 Whitewater Drive Suite 100, Minnetonka, 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 one of three person whose record was reviewed (P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment as required. The license holder failed to provide P2, whose service admission date was February 1, 2023, with orientation to their internal and external report reporting procedures of alleged or suspected maltreatment within 24 hours of admission. Corrective Action Ordered: Within 60 days of receipt of this order, you must provide P2 with the above-mentioned orientation and maintain documentation of that orientation as required in Minnesota Statutes, section 245D.095, subdivision 3. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide service recipient rights as required. The license holder failed to provide P1 with a written notice that identified the service recipient’s rights in subdivisions 2 and 3 and an explanation of those rights within five working days of service initiation. The license holder initiated services for P1 on January 22, 2022; however, these rights were not provided to P1 until April 3, 2022. Corrective Action Ordered: On an ongoing basis, you must provide service recipient rights as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not develop, document and implement a policy and procedure for the emergency use of manual restraints as required. The license holder developed two policies for the emergency use of manual restraint: one that did allow for the emergency use of manual restraints, and one that did not allow for the emergency use of manual restraints. The license holder was unable to ensure that both policies were not documented, implemented and distributed in the program. Corrective Action Ordered: Within 60 days of receipt of this order, you must revise your emergency use of manual restraint policy to state whether you allow or do not allow the emergency use of manual restraints in your program. You must ensure all service recipients receive a copy of this policy and all staff are trained on this policy. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not document health service needs as required. a. The license holder failed to implement health service needs for P1 as documented in their support plan. SP3 stated they were not responsible for any health service needs for P1. However, P1’s support plan addendum, developed by SP3 and signed by P1’s support team on April 10, 2023, documented that the license holder was responsible for the following health needs: · medication assistance including implementing physician’s orders from all medical, dental and other appointments; and · assisting with ordering and picking up medications. SP3 stated staff will drive P1 and P1’s legal representative to the pharmacy to pick up medications and administer over the counter medications as needed to P1; however, this was not documented in P1’s plan. The license holder failed to implement P1’s plan as written. b. P3’s support plan addendum, signed by P3’s support team on May 15, 2022, documented that the license holder would be assigned the health need of medication assistance. There was an authorization in P3’s support plan addendum that allowed the license holder to administer medication. The license holder stated they did not do any medication administration, assistance, or medication set up for any individuals they serve. When asked about P3’s support plan addendum that assigned the health need of medication assistance, the license holder stated staff provide over the counter medications as needed. The license holder failed to maintain documentation on how this health need will be met, including the description of the procedures will follow to assist with medications. Corrective Action Ordered: Within 60 days of receipt of this order you must: · review and revise as needed P1 and P3’s support plans to state what staff are responsible for in regard to their health service needs; · review the revised plan with P1 and P3’s support team, and maintain documentation that the team has reviewed this plan; · train all staff working with P1 and P3 on the updated plans and ensure all plans are being implemented as written. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide services that complied with the requirements of Chapter 245D and the federal waiver plans. The license holder provided individualized home supports to P1, who is a minor. According to the federal waiver plan, a minor cannot receive this service. Corrective Action Ordered: Immediately upon receipt of this order, you must contact P1’s case manager to reassign services that are compliant with the federal waiver plan. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose record was reviewed (P1 and P3), the license holder did not provide services in response to the person’s desired outcomes as specified in the person’s support plan and support plan addendum as required. a. The license holder implemented an outcome for P3 on April 29, 2022; however, the license holder failed to collect data for P3’s outcome. b. The license holder implemented an outcome for P1 on April 1, 2023. The license holder failed to collect data on P1’s outcome. Corrective Action Ordered: Immediately upon receipt of this order, you must implement P1 and P3’s supports and outcomes, including data collection of their progress towards achievement. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 7. 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 and delivery requirements of a basic service as required. The license holder completed a preliminary support plan addendum for P1 on February 3. 2022; however, the license holder failed to 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. There was a 45-day planning meeting document in P1’s file for night supervision; however, this plan was not dated, and it could not be determined when this meeting occurred. The license holder did review the plan with P1’s support team on April 23, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as require with this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for an intensive service as required. The license holder initiated individualized home support with training for P1 after April 1, 2022, (the license holder was unable to provide the exact date of service initiation). The license holder failed to complete the following within 45 days of service initiation: · Assessments in the following areas: o P1’s ability to self-manage health and medical needs to maintain or improve physical, mental and emotional well-being including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of treatments orders, preventative screening, and medical and dental appointments; o P1’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; o P1’s ability to self-manage symptoms or behavior that might otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and safety of the person others. · A 45-day planning meeting before providing 45 days of service, or within 60 calendar days of service initiation. The license holder did not meet with P1, P1’s legal representative, P1’s case manager, and other members of P1’s support team or expanded support team to determine the following based on the assessments listed above: o the person’s identified needs in the coordinated service support plan, and the requirements regarding service outcomes and reports and person centered planning and service delivery: § the scope of services to be provided to support the person’s daily needs and activities; § the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; § the person’s preferences for how services and supports are provided, including how the provider will support the person to have control over their schedule; § whether the current service setting is the most integrated setting available and appropriate for the person; § opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; § opportunities for community access, participation, and including preferred community activities; § opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; § opportunities to seek competitive employment and work at competitively paying jobs in the community; and § how services would be coordinated across all other providers licensed under this chapter who serve 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 § a discussion of how technology might be used to meet the person’s desired outcomes and a summary of that discussion. The license holder documented and discussed this information for P1 with P1 and P1’s support team on April 10, 2023. The license holder did have a 45-day planning meeting document in P1’s file; however, it was not dated and it only addressed the service of night supervision. Corrective Action Ordered: On an ongoing basis, you meet service planning and delivery requirements for an intensive service as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop outcomes as required. The license holder failed to develop a service plan for P1 that documented service outcomes and supports based on the assessments and person-centered planning within ten working days of the 45-day planning meeting. The license holder began providing an intensive service for P1 in April 2022; however, the service outcomes were not developed until March 29, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not review and evaluate the service plan as required. The license failed to develop and collect data on outcomes for P1 and P3, therefore, the license holder failed to provide progress reports that summarized the person’s progress towards achieving identified outcomes. Corrective Action Ordered: Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For one of four staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required. The license holder failed to provide the following trainings to SP2, whose hire date was August 22, 2022, 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 Minnesota Statutes, section 245D.06, subdivision 1; o following safety practices established by the license holder and as required under Minnesota Statutes, section 245D.06, subdivision 2; · the license holder’s current policies and procedures required under Minnesota Statute, chapter 245D, including their location and access, and staff responsibilities related to implementation of those policies and procedures; · data privacy requirements according to Minnesota Statutes, sections 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 ensuing the exercise and protection of those rights according to the requirements in Minnesota Statues, section 245D.04: · sections 245A.65, 245A.66, and 626.557 and Chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · principles of person-centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to the direct support services provided by the staff persons; · 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 restraints; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or elimination symptoms or undesired behavior; and why such procedures are not safe; · basic first aid; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · orientation to individual needs prior to having unsupervised direct contact including; o the person’s support plan and support plan addendum as it relates to the responsibilities assigned to the license holder to achieve an understanding of the person as a unique individual and how to implement those plans. Corrective Action Ordered: Within 60 days of receipt of this order, you must provide SP2 with the above-mentioned trainings. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual staff training as required. The license holder failed to provide the following trainings to SP1 annually in 2022 – 2023: · data privacy requirements according to Minnesota Statutes, 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 ensuing the exercise and protection of those right according to the requirements in Minnesota Statutes, section 245D.04; · sections 245A.65, 245A.66, and 626.557 and chapter 260E, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protection of persons from maltreatment and reporting maltreatment; · the principle of person-centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services 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. Corrective Action Ordered: Within 60 days you must provide SP1 with the above-mentioned trainings. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP4), the license holder did not maintain personnel records as required. The license holder failed to document the date of the training for all SP4’s trainings. Corrective Action Ordered: Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision 14. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not inform of the policies and procedures that affect a person’s rights as required. The license holder failed to inform and provide copies of the following policies and procedures to P2 and P2’s case manager within 5 working days of service initiation: · grievance; · service suspension; · service termination: and · emergency use of manual restraints. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide the above-mentioned policies and procedures to P2 and P2’s case manager. In addition, you must obtain a written acknowledgement from P2 that P2 received the emergency use of manual restraint policy and procedures as required in Minnesota Rules 9544.0080, subpart 1. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 15. Citation: Minnesota Statutes, section 245D.081, subdivision 2 paragraph (b). 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 coordinator identified by the license holder (SP3) failed to provide supervision, support, and evaluation of the activities that include: · oversight of the license holder’s responsibilities as assigned in the person’s 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 coordinated service support plan and service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcome had been achieved according to the requirements in section 245D.07. The failed to provide supervision, support, and evaluation of the activities listed above is evidence in citations 1 – 14. Corrective Action Ordered: Within 30 days of receiving this order, you must submit the name of the person that you have hired to perform the duties of the designated coordinator. You must verify and document their competence according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivision 2. You must submit the name of the person and a detailed description of how they are qualified to perform the duties of the designated coordinator. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with this subdivision. 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 service provided as required. The designated managers identified by the license holder (SP3), failed to provide program management and oversight of the service provided by being responsible for the following: · maintaining a current understating of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable as identified in 256B.04, subdivision 21, paragraph (b); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision (2); and · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 4, 4a, and 5. The failure to provide program management and oversight of the service provided is evidenced in citations 1 – 14. Corrective Action Ordered: Within 30 days of receiving this order, you must submit the name of the person that you have hired to perform the duties of the designated manager. You must verify and document their competence according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3. You must submit the name of the person and a detailed description of how they are qualified to perform the duties of the designated manager. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required with 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 diana.arnzen@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: Diana Arnzen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 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 me as soon as possible. Diana Arnzen, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-6638
|
