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August 25, 2023 Funmilayo Christiana Igboh, Authorized Agent Golden Healthcare LLC 8405 Yates Avenue North, Suite 209 Brooklyn Park, Minnesota 55443 License Number: 1108638 (245D – HCBS) CORRECTION ORDER Dear Funmilayo Christiana Igboh: On August 8, 2023, a licensing review of Golden Healthcare LLC, located at 8525 Edinbrook Crossing North, Suite 209, 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. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one of one person whose record was reviewed (P1), the license holder did not provide orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. P1’s services were initiated on June 1, 2022. The license holder failed to provide P1 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder later provided this orientation to P1 on July 15, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. SP1 was hired on June 1, 2022. The license holder failed to provide SP1 with an orientation to the following within 60 days of hire: · 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 (HIPAA), and staff responsibilities related to complying with data privacy practices. SP1 received this training on September 18, 2022; · 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. SP1 received this training on September 18, 2022; · the principles of person-centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. SP1 received this training on September 18, 2022; · 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; · 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; · basic first aid. SP1 received this training on September 1, 2022; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. b. SP2 was hired on June 1, 2022. The license holder failed to provide SP2 with an orientation to the following within 60 days of hire: · 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 (HIPAA), and staff responsibilities related to complying with data privacy practices. SP2 received this training on August 3, 2022; · the principles of person-centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. SP2 received this training on August 28, 2022; · 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. SP2 received this training on August 28, 2022; · 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. SP2 received this training on August 28, 2022; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. SP2 received this training on August 19, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with training on the topics identified above. Additionally, you must maintain documentation of this training in SP1’s personnel record as required in Minnesota Statutes, section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain a personnel record for SP2 that included documentation of the date of SP2’s first supervised direct contact with a person served by the program and the date of SP2’s 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. 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. 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 Amber Nielsen at 651-431-3661 or amber.n.nielsen@state.mn.us as soon as possible. Christala Culhane, HCBS Licensing Supervisor Licensing Division Office of Inspector General
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