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November 22, 2023 Muhamed Caaje, Authorized Agent Minnesota Multi Cultural Health Services LLC 4111 Central Avenue Northeast Suite 208E Columbia Heights, Minnesota 55421 License Number: 1087769 (245D – HCBS) CORRECTION ORDER Dear Muhamed Caaje: On September 22, 2023, a licensing review of Minnesota Multi Cultural Health Services LLC, located at 4111 Central Avenue Northeast, Columbia Heights, 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 2, paragraph (b), clause (1) and section 626.557, subdivision 14, paragraph (b). Violation: For one of six persons whose record was reviewed (P6), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop an IAPP for P6 that included an individualized assessment. The license holder developed an IAPP for P6 that documented P6 was not susceptible to self-abuse, sexual abuse, or financial abuse. This information was inconsistent with other information found in P6’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P6’s IAPP to include an individualized assessment of P6’s susceptibility to abuse and statements of specific measures for any areas where P6 is assessed to be vulnerable to abuse. On an ongoing basis, you must maintain compliance as required in these subdivisions. Repeat Violation: In an Order of Conditional License that DHS issued on February 27, 2023, you were cited for a similar violation. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (3). Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation of the person’s receipt of a written notice that identified service recipient rights and an explanation of those rights as required. The license holder provided P1 with the copy of the service recipient rights and an explanation of those rights on March 27, 2023. The license holder failed to maintain documentation of P1’s receipt of the copy and an explanation of the rights. Corrective Action Required: Within 30 days of receiving this order, you must maintain documentation in P1’s record that P1 was provided a written notice that identified service recipient rights and an explanation of the rights. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In an Order of Conditional License that DHS issued on February 27, 2023, you were cited for a similar violation. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not complete a preliminary support plan addendum as required. P2’s services were initiated on August 27, 2023. The license holder failed to complete a preliminary support plan addendum for P2 within 15 calendar days of service initiation. Corrective Action Required: Within 30 days of receiving this order, you must complete a basic service preliminary support plan addendum for P2. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In an Order of Conditional License that DHS issued on February 27, 2023, you were cited for a similar violation. 4. Citation: Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not obtain a written acknowledgement from the person when the license holder informed the person of the license holder’s policy on the emergency use of manual restraint as required. The license holder failed to obtain a written acknowledgement from P1 at the time services were initiated that indicated that P1 had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, section 245D.04. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain a written acknowledgement from P1 that they have been notified of your policy on the emergency use of manual restraints. On an ongoing basis, you must maintain compliance as required in this part. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two of five staff persons whose records were reviewed (SP1 and SP5), the license holder did not provide annual training 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 SP1 with training on the following required training topics on an annual basis. The license holder provided orientation training to SP1 in April 2022 and provided annual training on the following topics in June 2023: · data privacy requirements according to sections 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; · 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; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service 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; and · 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. b. The license holder failed to provide SP2 with training on the following required training topics on an annual basis. The license holder provided orientation training to SP2 in April 2022 and provided annual training on the following topics in August 2023: · 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; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service 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; 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: On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In an Order of Conditional License that DHS issued on February 27, 2023, you were cited for a similar violation. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP3 and SP5), the license holder did not maintain personnel records as required.
a. The license holder failed to maintain an acknowledgment in SP1 and SP3’s personnel records that was signed by the employee that the job duties were reviewed with the staff person and the staff person understood those duties. b. The license holder failed to maintain a personnel record for SP5 that included documentation of annual training, including the date the training was completed, in August 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · audit all staff personnel records to ensure each staff person has a signed acknowledgment signed by the staff person that the job duties were reviewed with the staff person and the staff person understood those duties; and · for any staff person who does not have a signed acknowledgement, you must review the job duties with the staff person and obtain a signed acknowledgement that the job duties were reviewed with the staff person and the staff person understood the duties. You must maintain the signed acknowledgement in each staff person’s personnel record. 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 Kris Oberg at 651-431-6589 as soon as possible. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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