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Notice: This Amended Correction Order supersedes the original Correction Order dated April 24, 2023. This document is amended to remove citation number 6. Citation 1 and any reference to the total number of citations issued was amended to reflect the number of citations based on the results of the reconsideration. The original Correction Order dated April 24, 2023, must be destroyed. Date Issued: April 24, 2023 Date reissued: September 1, 2023 Abdisalan Sabriye, Authorized Agent Sun Home Health Care 1700 North Broadway Avenue Suite 114 Rochester, MN 55906 License Number: 1077422 (245D – HCBS) AMENDED CORRECTION ORDER Dear Abdisalan Sabriye: On January 25, 2023, a licensing review of Sun Home Health Care located at 1700 North Broadway Avenue, Suite 114, Rochester, 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 Rules, part 9544.0030, subparts 1 and 2. Violation: For one of one person whose record was reviewed (P1), the license holder did not evaluate positive support strategies and person-centered planning as required. The license holder failed to develop and implement positive support strategies for P1 according to the standards in subpart 2, and failed to incorportate principles of person-centeredness into the services provided. Additionally, the license holder failed to evaluate with P1 identified positive support strategies at least every six months. Corrective Action Ordered: Within 60 days of receiving this order, you must document the positive support strategies and person center planning for P1 required in these subparts. You are also ordered to submit evidence to your licensor that this was completed. On an ongoing basis, you must evaluate with the person, at least every six months, whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one person whose records was reviewed (P1), the license holder did not provide an orientation to the internal and external reporting procedures of alleged and suspected maltreatment as required. P1`s service initiation was on December 14, 2021. The license holder failed to provide orientation to the internal and external reporting procedures of alleged and suspected maltreatment to P1 within 72 hours of service initiation. Corrective Action Ordered: Within 60 days of receiving this order you must provide orientation to the internal and external reporting procedures of alleged and suspected maltreatment to P1. You are also ordered to submit evidence that P1 received this information. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet requirements for an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1 as part of the initial service plan. P1’s services were initiated on December 14, 2021, however, the license holder failed to develop an IAPP for P1. The license holder maintained a document titled “Vulnerability and Safety Assessment” dated February 2, 2022 and indicated that this was the initial assessment of P1’s vulnerabilities. P1’s “Vulnerability and Safety Assessment” indicates that P1 is susceptible to all areas identified. However, the license holder failed to include a statement of specific measures, including the specific actions that the license holder would take to minimize the risk of abuse within the scope of services, when the assessment required in section 626.557, subdivision 14, indicated P1’s susceptibility to physical abuse, sexual abuse, self-abuse, financial exploitation, and when the program was aware of P1 committing a violent crime or act of physical aggression toward others. Corrective Action Ordered: Within 60 days of receiving this order you must develop P1’s IAPP to include an individualized assessment of P1’s susceptibility to abuse by other individuals. You must submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide a written notice that identified the service recipient rights as required. P1’s service initiation was on December 14, 2021. The license holder failed to provide P1 with a written notice that identifies the service recipient rights and an explanation of those rights within five working days of service initiation. Additionally the license holder failed to provide written notice of service recipient rights in 2022. Corrective Action Ordered: Within 60 days of receiving this order you must provide P1 with written notice that identified the service recipient’s rights. You must submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for basic support services as required. The license holder failed to do the following: · complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation; · 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 within 60 calendar days of service initiation; · participate in service planning and support team meetings for the person following stated timeline established in the person’s support plan or as requested by the person or the person’s legal representative, the support team or the expanded support team; and · provide written reports regarding their progress or status as requested by the person, the case manager, or team.
Corrective Action Ordered: Within 60 days of receiving this order you must complete a support plan addendum based on the support plan that includes how, when and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services. Additionally, you must submit written documentation on how compliance will be maintained in the future to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose records were reviewed (P1), the license holder did not maintain a service recipient record as required. The license holder failed to maintain the progress or daily log notes that are recorded by the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P1 and P1’s case manager of the policies and procedures and provide copies of the following policies and procedures within five working days of service initiation: · Grievance policy; · Temporary service suspension policy; · Service termination policy; and · Emergency use of manual restraints policy. Corrective Action Ordered: Within 60 days of receiving this order, you must inform P1 and their case manager of the above-mentioned policies and provide copies of the policies as required in this subdivision. You must submit this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D. 09, subdivision 4. Violation: For one of two staff persons whose records were reviewed (SP1), the license holder did not provide orientation training as required. SP1 began a position as a direct support staff providing basic support services on December 14, 2021. The license holder failed to provide strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action: Within 60 days of receiving this order, you must provide SP1 with the above-mentioned training. On an ongoing basis, you must provide orientation training as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff persons whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required. SP1 had unsupervised direct contact with a person served by the program on December 20, 2021. The license holder indicated that SP1 received orientation to individual service recipient needs were provided on December 9, 2021. However, the license holder failed to review and provide instruction on the following as it relates to the responsibilities assigned to the license holder: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan. Corrective Action: Within 60 days of receiving this order, you must provide SP1 with the above training. You must submit documentation of this training as required in 245D.095, subdivision 5, paragraph (a) clause (2) to your licensor. On an ongoing basis, you must provide annual training as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a) and (b). Violation: For one staff person whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. The license holder failed to document the following information in SP2’s personnel record: · 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. Corrective Action Ordered: Within 60 days of receiving this order, you must maintain the abovementioned information in SP2’s personnel record and submit written documentation that the above-mentioned requirements are documented in SP2’s personnel record. On an ongoing basis, you must maintain personnel records for all staff as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.081, subdivision 2. 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 coordinated identified by the license holder (SP2) failed to provide supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s service and support plan and the service and support plan addendum; · taking the necessary action 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 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 has been achieved according to the requirements in section 245D.07 The failure to provide coordination and evaluation of individual service delivery is evidenced in citations 1 through 11. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person other than SP2, to be appointed as the designated coordinator, who is responsible for delivery and evaluation of services provided by the license holder; and · submit the name, contact information and qualifications of the person(s) you have designated and have ensured is competent to perform the duties of the designated coordinator as required in this section. 12. 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 services provided as required. The designated manager identified by the license holder (SP3) failed to provide program management and oversight of the services provided by being responsible for the following: · maintaining a current understanding of the license requirements sufficient to ensure compliance throughout the program; · ensuring the duties of the designated coordinator are fulfilled; and · ensuring staff competency requirements are met. The failure to provide program management and oversight of services provided is evidenced in citations 1 through 11. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person, other than SP3, to be appointed as the designated manager, who is responsible for delivery and evaluation of services provided by the license holder; · submit the name, contact information and qualifications of the persons(s) you have designated and ensured is competent to perform the duties of the designated manager as required in this section. 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 nicole.m.riley@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: Nicole Riley 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 Nicole Riley, Senior Licensor, at 651-431-3657, as soon as possible. Christala Culhane, Human Services Licensor Licensing Division Office of Inspector General
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