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August 15, 2023 Abdisalan Sabriye, Authorized Agent Sun Home Health Care 1700 North Broadway Avenue Suite 114 Rochester, MN 55906 RE: Request for Reconsideration of Correction Order License Number: 1077422 (245D - HCBS) Dear Abdisalan Sabriye: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of three of thirteen citations in a Correction Order (Attachment A) issued to you by the Department of Human Services on April 24, 2023. After an independent review of the record, the Commissioner has determined that there is sufficient evidence to support the two of three challenged citations. Reconsideration Determination Citation 6. Citation 6 was issued because for one person whose record was reviewed (P1), the license holder did not meet service plan review and evaluation requirements. Applicable Law. The license holder must give the person or the person's legal representative and case manager an opportunity 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 subdivisions 3 and 4. Minnesota Statutes, section 245D.071, subdivision 5. Your Response. You contend you were not required to give the case manager or legal representative an opportunity to participate in ongoing meetings because P1 only receives basic services rather than intensive services. You state section 245D.071 applies only to intensive services. Reconsideration Determination. Since P1 receives basic, rather than intensive services progress meetings are not required. As a result, there is no violation of Section 245D.071. Service plan requirements for recipients of basic services are provided under Minnesota Statutes, Section 245D.07, subdivision 2, paragraph D. Under this statute, progress meetings are not required absent a request from the recipient, their legal representative, support team, or expanded support team. In this case, no such request was made. Therefore, there is insufficient evidence to support citation 6 and it is rescinded. Citation 7. Citation 7 was issued because for one person whose records were reviewed (P1), the license holder did not maintain a service recipient record as required. Specifically, the license holder failed to maintain the progress or daily log notes that are to be recorded by the program. Applicable Law. License holders must maintain progress review reports as required under section 245D.071, subdivision 5, and progress or daily log notes that are recorded by the program for each person. Minnesota Statutes, section 245D.095, subdivision 3. Your Response. You state that you maintain records by use of timesheets. You indicate that log notes are documented directly on the timesheets. Staff personnel reportedly write the time-in and time-out as well as place initials next to what task was completed. The time sheet is then turned in once it is signed by the SP1 and P1. You state these documents were available for inspection had the licensor requested them. Reconsideration Determination. Your method of marking general tasks completed is insufficient. Your notes do not indicate how a person’s services were implemented, the person’s involvement, or progress made for each individual person. Further, Minnesota Statutes 245D.09, subdivision 3, requires the progress or daily notes be in each person served, service recipient records, not in the facility’s personnel files. Since the timesheet method used to document services provided is insufficiently detailed, there is sufficient evidence to support citation 7 and it is affirmed. Citation 11. Citation 11 was issued because for one staff person whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. Applicable Law. The license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, and training. The personnel record must include: the employee’s date of hire, completed application, an acknowledgment signed by the employee that job duties were reviewed with the employee and the employee understands those duties. Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a) and (b). Your Response. You state that a portion of this citation is in error, because you contend a completed application with date of hire is in the employee’s file. Reconsideration Determination. You failed to maintain the personnel record for the HCBS program. The document you provided to the licensors at the licensing review was a personnel record from 2011, when the program was a PCA organization and the program was not licensed as a 245D-HCBS program until 2015. You did not maintain documentation of the employees date of hire, completed application, or an acknowledgment that they reviewed and understood their job duties for the HCBS program under review, as required by Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a) and (b). Since, there is sufficient evidence to support citation 11 and it is affirmed. Disposition The Commissioner has reviewed the relevant laws and all of the information you submitted in response to the Correction Order. The record supports the two of the three citations, and those two citations are affirmed. DHS will issue an Amended Correction Order reflecting the recission of Citation 6. This is a final agency decision. Sincerely,
Kofi Montzka, Attorney Legal Counsel’s Office Office of Inspector General
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