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November 27, 2023 CERTIFIED MAIL Abdifatah Soyan, Authorized Agent Better Home Health Care Inc 1433 E Franklin Ave, Ste 7E Minneapolis, MN 55404 License Number: 1081943 (245D – Home and Community-Based Services) ORDER OF CONDITIONAL LICENSE Dear Abdifatah Soyan: The Department of Human Services (DHS) is placing your license to provide Home and Community-Based Services (HCBS) for Better Home Health Care Inc, located at 1433 East Franklin Avenue, Suite 7E, Minneapolis, Minnesota on conditional status for two years, beginning November 27, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with HCBS licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On June 27, 2023, DHS licensors conducted a licensing review at your facility located at 1433 East Franklin Avenue, Suite 7E, Minneapolis, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Home and Community-Based Services, citing 15 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in this Order of Conditional License are violations of law or rule affecting the health, safety, or rights of persons served by the program. The licensing violations include: o Failure to provide program coordination, evaluation, and oversight by a designated coordinator and designated manager o Failure to meet the requirements for providing the orientation to service recipients regarding to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults o Failure to meet the requirements for the completion of individual abuse prevention plans for persons served o Failure to develop and incorporate positive support strategies and person-centered planning o Failure to meet the requirements for basic and intensive service planning and delivery o Failure to meet the requirements for the completion of the assessments for persons served o Failure to provide orientation training to staff o Failure to maintain service recipient records · Chronicity: The license holder was non-compliant across many areas of licensed service delivery and identified violations were not isolated to one area of concern. Non-compliance was found in record requirements, service recipient service delivery, staff orientation training, program coordination, program evaluation, and program oversight. Your program received its license on June 17, 2016. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o November 27, 2023 Conditional License (this order): 15 violations (3 repeat violations) o June 10, 2019 Correction Order: 5 violations · Severity: Many of the violations that led to this Order of Conditional License relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Home and Community-Based Services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violations 1. 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 coordinators (SP1 and SP2) were competent to perform the required duties, including the supervision, support, and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan and 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 support plan and the service outcomes, including the failure to have an established process in which the designated coordinator determines the competency of the person that has been has delegated the responsibility to directly observe the service delivery activities to assess staff competency; · 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. The failure to provide program coordination and oversight of the services provided is evidenced in citations 2 through 15. b. The license holder failed to ensure that the designated manager (SP1) was competent to perform the required program management and oversight of the services provided by the license holder, included: · 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; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the services provided is evidenced in citations 1 through 15. Statute Violated: Minnesota Statutes, section 245D.081 Service Recipient Violations 2. Violation: For one of six persons whose records were reviewed (P3), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder provided P3 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission; however, the license holder failed to notify P3’s legal representative of the orientation. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c). 3. Violation: For five persons whose record was reviewed (P2- P6), the license holder did not meet the requirements for individual abuse prevention plans (IAPP) as required. a. For P2, the license holder failed to include an individualized assessment of P2’s susceptibility of abuse. P2’s IAPP stated P2 was not susceptible to abuse; however, this assessment was not consistent with information reviewed elsewhere in P2’s record. Information maintained in P2’s record referred to the IAPP to provide information regarding his/her physical and emotional health-related risks. The license holder also failed to review P2’s IAPP at least annually with P2’s interdisciplinary team. P2’s IAPP was last reviewed on January 20, 2021. b. For P3, the license holder failed to develop an IAPP as part of the initial individual service plan. P3’s services were initiated on May 9, 2022 and the license holder developed the IAPP on June 11, 2022. The license holder also failed to include an individualized assessment of P3’s susceptibility of abuse. P3’s IAPP stated P3 was not susceptible to abuse; however, the assessment was not consisted with information reviewed elsewhere in P3’s record. c. For P4, the license holder a failed to include an individualized assessment of P4’s susceptibility of abuse. P4’s IAPP stated P4 was not susceptible to abuse; however, the assessment was not consisted with information reviewed elsewhere in P4’s record. The license holder also failed to review P4’s IAPP at least annually with P4’s interdisciplinary team. P4’s IAPP was developed on November 6, 2020 and reviewed on May 10, 2023. d. For P5, with a service initiation date of October 1, 2022, the license holder failed to develop an IAPP as part of the initial individual service plan. The license holder completed an IAPP for P5 on December 16, 2022. e. For P6, with a service initiation date of August 24, 2020, the license holder failed to develop an IAPP prior to or upon service initiation. The license holder developed P6’s IAPP on September 1, 2020. The license holder also failed to review P6’s IAPP annually. The license holder failed to review P6’s IAPP in 2021 or in 2022. The license holder reviewed P6’s IAPP on May 10, 2023. Additionally, the license holder failed to include an individualized assessment of P6’s susceptibility of abuse. P6’s IAPP stated P6 was not susceptible to abuse; however, the assessment was not consisted with information reviewed elsewhere in P6’s record. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Repeat Violation: The license holder was cited for a similar violation in a correction order dated June 10, 2019. 4. Violation: For five persons whose records were reviewed (P1 – P4, and P6), the license holder did not provide the service recipient rights as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder failed to provide P3’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation and on an annual basis. The license holder provided the notice to P3 on May 9, 2022, but failed to provide a notice to P3’s legal representative. b. The license holder failed to provide P1, P2, P4, and P6 with a written notice that identified the service recipient rights and an explanation of those rights annually. · P1 was provided the notice on May 29, 2021. · P2 was provided the notice on February 2, 2021. · P4 was provided the notice on November 6, 2020, November 9, 2020, and September 2, 2021. · P6 was provided the notice on August 26, 2020, and May 2, 2023. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. 5. Violation: For five persons whose records were reviewed (P1, P2, and P4-P6), the license holder did not provide services in compliance with the requirements of this chapter and federal waiver plan. a. Regarding P2, and P4-P6, the license holder provided multiple services to each service recipient. The license holder failed to develop a support plan addendum for P2, and P4-P6 that identified how services would be provided for each service the person was receiving, including, how, when, and by whom. b. Regarding P1 and P2, on the day of the licensing review DHS licensors asked the license holder to provide documentation regarding the services provided to P1, and P2. The license holder was unable to provide any documentation. The license holder failed to provide services to P1 and P2 according to the federal waiver plan. Statute Violation: Minnesota Statutes, section 245D.07, subdivision 1. 6. Violation: For three persons whose records were reviewed (P2, P5 and P6), the license holder did not meet service planning requirements for basic support services as required. a. For P2, P5, P6, the license holder failed to, within 60 days of service initiation, review, and revise, as needed, the preliminary support plan addendum to document the services that would be provided, including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. b. For P6, the license holder failed to follow stated timelines for service planning meetings. P6's support plan stated meetings would take place annually. At the time of the review, no annual meeting had occurred. Statute Violation: Minnesota Statutes, section 245D.07, subdivision 2. 7. Violation: For one person whose record was reviewed (P6), the license holder did not meet requirements for progress reports. The license holder was responsible for annual reports for P6. The license holder failed to complete and maintain progress reports as required in the support plan. Statute Violation: Minnesota Statutes, section 245D.07, subdivision 3. 8. Violation: For one person whose record was reviewed (P1), the license holder did not meet initial service planning requirements as required. The license holder failed to complete a preliminary support plan addendum within 15 days of service initiation for P1. P1’s services were initiated on May 27, 2021 and the preliminary support plan addendum was completed on June 16, 2021. Statute Violation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (a). 9. Violation: For three persons whose records were reviewed (P1, P3 and P4), the license holder did not meet service planning and delivery requirements for intensive services as required. a. The license holder failed to complete assessments in the following areas for P1 and P4: · the 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 medication or treatment orders, preventative screening, and medical and dental appointments; · the 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; and · the ability to self-manage symptoms or behavior that may 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 welfare of the person or others. b. Although the license holder completed assessments for P3, the license holder failed to ensure the assessments produced information about P3’s overall strengths, functional skills, and abilities. c. For P1, P3, and P4, the license holder failed to conduct a 45 day service planning meeting. The license holder failed to meet with the person, the person’s legal representative (if applicable), the person’s case manager, and other members of the support team or expanded support team to determine the following based on the information obtained from the assessments: · The person’s identified needs in the CSSP, and the requirements regarding service outcomes and reports and person centered planning and delivery: · the scope of the services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and the supports necessary to accomplish P1’s desired outcomes; · the person’s preferences of how services and supports are provided, including how the provider will support the person to have control of the person’s 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 inclusion in 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; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure the continuity of care and coordination of services for the person; · a discussion of how technology might be used to meet the person’s desired outcomes; and · maintain a summary in the person’s support plan addendum of that discussion that included a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). 10. Violation: For three persons whose records were reviewed (P1, P3, and P4), the license holder did not develop service outcomes and supports as required. The license holder failed to develop and document the supports and methods to be implemented for P1, P3, and P4 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. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4. 11. Violation: For two person whose record was reviewed (P1 and P4), the license holder did not meet service plan review and evaluation as required. a. For P1, the license holder failed to: · meet with P1, P1’s legal representative, P1’s case manager, and other members of the support team at least annually. The license holder did not meet annually in 2022 and 2023; · discuss with P1, P1’s legal representative, case manager, and other members of the support team about how technology might be used to meet P1's desired outcomes at least once per year in 2022 and 2023; and · summarize P1’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods. b. For P3, the license holder failed to: · although the license met with P3 on March 20, 2023, the license holder did not involve P3’s legal representative, case manager, or other members of the support team in the meeting. The license holder did not meet annually with P3’s support team in 2023; · discuss with P3, P3’s legal representative, case manager, and other members of the support team about how technology might be used to meet P3's desired outcomes at least once per year in 2023; and · summarize P3’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods. c. For P4, the license holder failed to: · meet with P4, P4’s case manager, and other members of the support team at least annually. The license holder did not meet annually in 2022 and 2023; · discuss with P4, P4’s legal representative, case manager, and other members of the support team about how technology might be used to meet P4's desired outcomes at least once per year in 2022 and 2023; 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 supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. 12. Violation: For six persons whose record was reviewed (P1- P6), the license holder did not provide written or electronic copies of policies and procedures affecting a person’s rights under section 245D.04 as required. a. For P1-P6, the license holder failed to inform and provide copies of the following policies and procedures to the person’s case manager within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · for P1—P3, and P6, data privacy requirements. At the time of the licensing review conducted on June 27, 2023, the license holder had not provided these policies to P1-P6’s case managers. b. For P3, the license holder failed to inform and provide copies of the policies and procedures that affect a person’s rights under section 245D.04 to P3’s legal representative within five working says of service initiation. At the time of the licensing review conducted on June 27, 2023, the license holder had not provided these policies to P3’s legal representative. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4. Repeat Violation: The license holder was cited for a similar violation in a correction order dated June 10, 2019. 13. Violation: For six persons whose records were reviewed (P1- P6), the license holder did not incorporate and evaluate positive support strategies as required. For P1-P6, the license holder failed to incorporate positive support strategies in writing to an existing treatment, service, or other individual plan. Additionally, the license holder failed to evaluate with P1-P6 at least every six months, whether any positive support strategies used, needed changes, and if so, made the appropriate changes. Rule Violated: Minnesota Rules, part 9554.0030. Staffing Standards Violations 14. Violation: For three of five staff persons whose records were reviewed (SP3-SP5), the license holder did not provide orientation to program requirements and individual service recipient needs. a. For SP3 with a hire date of May 21, 2020, the license holder failed to provide orientation to the following: · basic first aid; · strategies to minimize the risk of sexual violence; and · instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, which would include the person’s IAPP. b. For SP4 with a hire date of January 27, 2023, the license holder failed to provide orientation to the following: · strategies to minimize the risk of sexual violence; and · instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, which would include the person’s IAPP. c. For SP5 with a hire date of November 25, 2020, the license holder failed to provide orientation that included instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, which would include the person’s IAPP. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Repeat Violation: The license holder was cited for a similar violation in a correction order dated June 10, 2019. Records Requirements 15. Violation: For six persons whose records were reviewed (P1-P6), the license holder did not maintain service recipient records as required. a. Regarding P1, the license holder failed to maintain the following information in P1’s record: · P1’s current support plan or the portion of the plan assigned to the license holder; · a copy of P1’s assessment for 2023 required under section 245D.071, subdivisions 2 and 3; · P1’s progress review reports as required under section 245D.071, subdivision 5; and · progress or daily log notes recorded by the program. a. Regarding P3, the license holder failed to maintain the following information in P3’s record: · progress or daily log notes recorded by the program; and · although P3’s record included an admission form, the license holder failed to maintain an admission form that was signed by P3’s legal representative. b. Regarding P4, the license holder failed to maintain the following information in P4’s record: · At the time of the review, P4 was being provided individualized home supports with training and night supervision. The license holder failed to maintain information that included when P4’s services were initiated. The license holder was unable to determine the date each service was initiated; · a copy of P4’s assessment for 2023 required under section 245D.071, subdivisions 2 and 3; · P4’s progress review reports as required under section 245D.071, subdivision 5; and · progress or daily log notes recorded by the program. c. Regarding P5, the license holder failed to maintain the following information in P5’s record: · P5’s current support plan or the portion of the plan assigned to the license holder; · although P5’s record included an admission form, the license holder failed to maintain an admission form that was signed by P5’s legal representative; and · progress or daily log notes recorded by the program. d. Regarding P2, and P6, the license holder failed to maintain progress or daily log notes recorded by the program. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite on an ongoing basis. If you fail to demonstrate substantial compliance with HCBS requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from receipt of this Order, you must provide written notification of the conditional status of your license to all service recipients currently receiving home and community-based services from Better Home Health Care Inc. A copy of the notification must also be provided to their legal representatives and case managers. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, other than SP1 or SP2, who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP1, to provide program management and oversight of the services provided by the license holder; and · submit this staff person’s name and qualifications to your licensor for approval. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 45 days of receiving this order, you must: · submit a written plan detailing how you will ensure the corrective action ordered in this order is completed; and · submit a written plan to your licensor detailing how you will audit all participant and personnel records for compliance with all applicable rules and statutes. 4. Within 60 days of receiving this order, you must: · complete the audit of all participant and personnel records according to your written plan; · submit the results of the audit to your licensor; and · submit the date to your licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 5. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Admission of any new participant during the duration of the conditional license is only allowed with prior approval from DHS. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office ATTN: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not be imposed until a decision is issued by DHS. You continue to be required to comply with all HCBS laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · HCBS programs are required to follow Minnesota Statutes, chapters 245A, 245C, and 245D and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Christala Culhane, HCBS Unit Supervisor, at 651-431-6541. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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