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January 5, 2024 CERTIFIED MAIL Simon Nyamari, Authorized Agent Amani Health Care Services LLC 1705 Southcross Drive West Suite 105 Burnsville, Minnesota 55306-7012 License Number: 1091055 (245D - HCBS) ORDER OF A CONDITIONAL LICENSE - EXTENDING AN EXISTING CONDITIONAL LICENSE Dear Simon Nyamari: On January 31, 2022, the Department of Human Services (DHS) issued an Order of Conditional License to Amani Health Care Services LLC, located at 1705 Southcross Drive West, Suite 105, Burnsville, Minnesota. On December 12, 2023, DHS licensors conducted a licensing review to determine whether compliance with the Terms of the Conditional License had been met. As a result of this review, DHS determined seven home and community-based services licensing violations. As a result of your history of noncompliance with licensing requirements and your failure to comply with the terms of the January 31, 2022, Order of Conditional License, DHS is issuing a new Order of Conditional License to extend the existing conditional license until January 31, 2025. 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 the Order of Conditional License are violations of law or rules affecting the health and safety of the persons served by the program. The licensing violations include: o Failure to provide program coordination, evaluation, and oversight by a designated coordinator and a designated manager; 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; · Chronicity: Your program received its license on January 1, 2018. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o March 1, 2019, Correction Order: 18 violations o January 31, 2022, Order of Conditional License: 12 violations, 9 repeat violations o June 16, 2022, Correction Order: 2 violations, 2 repeat violations o February 28, 2023, Correction Order: 6 violations, 3 repeat violations o October 18, 2023, Correction Order: 7 violations, 4 repeat violations o January 5, 2024, Order of Conditional License (this order): 7 violations, 6 repeat violations · Severity: Many of the violations that led to the revocation of your license relate to the health and safety of persons served. Six of the seven violations determined at the most recent licensing review were repeat violations that you were previously ordered to correct. 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 (HCBS) is placed on a conditional status. Licensing Violations This order requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. At a licensing review conducted on December 12, 2023, DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight 1. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinators (SP3, SP4 and SP5) performed 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 7. In addition, the license holder failed to ensure the designated coordinators made the corrections order in a correction order dated October 18, 2023. b. The license holder failed to ensure that the designated managers (SP3 and SP4) performed the required program management and oversight of the services provided by the license holder, including: · 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 2 through 7. In addition, the license holder failed to ensure the designated managers made the corrections order in a correction order dated October 18, 2023. Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated February 23, 2022; and in a correction order dated March 1, 2019. Corrective Action Ordered: Within 30 days of receipt of this order, you must submit the name(s) of the person(s) other than SP3, SP4, and SP5 that will be your designated coordinator and designated manger. On an ongoing basis, you must ensure compliance as required in this subdivision. Service Recipient Violations 2. Violation: For three of four persons whose records were reviewed (P1, P2 and P3), the license holder did not develop individual abuse prevention plans as required. a. P1 and P3’s individual abuse prevention plans documented that staff were instructed to follow a protocol for the person. P1 and P3’s service recipient records did not include a protocol to follow. b. P1 received multiple services from the license holder. The license holder failed to document the statement of measures that would be taken to minimize the risk of abuse within the scope of each service P1 was receiving. c. P2’s individual abuse prevention plan indicated P2 was not at risk of sexual abuse, physical abuse, or financial exploitation. This assessment was not consistent with information reviewed elsewhere in P2’s record. The license holder failed to include an individualized assessment of P2’s susceptibility of abuse. d. P2’s individual abuse prevention plan indicated P2 was at risk of self-abuse. The license holder failed to document the statement of specific measures that would be taken to minimize the risk of abuse for P2. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated February 23, 2022; and correction orders dated March 1, 2019, June 16, 2022, February 28, 2023, and October 18, 2023. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · develop protocols as stated for P1 and P3 and train staff working with P1 and P3 on the protocol for the person. You must document this training in the staff persons’ personnel records; · review and revise P1’s individual abuse prevention plan to include a statement of measures that would be taken to minimize the risk of abuse within the scope of each service P1 receives; · review and revise P2’s individual abuse prevention plan to include an individualized assessment of P2’s susceptibility of abuse and to include statements of specific measures that the program would take to minimize the risk of abuse for each area where P2 is assessed to be vulnerable to abuse. On an ongoing basis, you must develop individual abuse prevention plans as required. 3. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not meet service planning and delivery requirements for a basic service as required. a. The license holder failed to document how P3’s services would be provided of P3’s service initiation. b. The license holder failed to document how P2’s services would be provided, including how, when, and by whom services would be provided. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (c). Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated February 23, 2022; and correction orders dated March 1, 2019, June 16, 2022, February 28, 2023, and October 18, 2023. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · review and revise P2 and P3’s support plan addendums to document how the person’s service will be provided, including how, when and by whom services will be provided; · audit all records of persons receiving a basic service from your program to ensure each person’s record documents how services will be provided. On an ongoing basis, you must maintain compliance as required with this subdivision. 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a as required. The license holder documented an outcome in P1’s support plan addendum. The license holder failed to document the following supports and methods to accomplish the outcome identified for P1: · the methods or actions that will be used to support the person and to accomplish the service outcomes including: o information about changes or modifications to the physical and social environments; o equipment and materials required; o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which the progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (a). Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated February 23, 2022, and October 18, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the supports and methods listed above for P1. On an ongoing basis, you must maintain compliance as required. 5. Violation: For one person whose record was reviewed (P4), the license holder did not review and evaluate the service plan as required. The license holder failed to complete progress reports for P4 that summarized P4’s status and progress towards achieving P4’s identified outcomes. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. Corrective Action Ordered: Within 30 days of receipt of this order, you must complete progress reports of P4’s identified outcomes that summarized P4’s status and progress toward achievement; make recommendations; and identify the rationale for changing, continuing, or discontinuing implementation of P4’s outcomes. On an ongoing basis, you must maintain compliance as required with this subdivision. 6. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not identify positive support strategies as required. The license holder failed to identify positive support strategies for P1-P3. Statute Violated: Minnesota Rule Part 9555.0030, subpart 1. Repeat Violation: The license holder was cited for a similar violation in a correction order dated March 1, 2019, and an order for conditional license dated February 23, 2022. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · assess P1-P3’s strengths, needs, and preferences to identify and create positive support strategies for each person; · incorporate the positive support strategies for P1 -P3 in writing to an existing treatment, service, or other individual plan for the person; and · you must audit all person served records to ensure you have identified positive support strategies for each person. 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. Record Requirements Violations 7. Violation: For one of two staff person whose record was reviewed (SP2), the license holder did not maintain personnel records as required. The license holder failed to document the date of the training on all SP2’s trainings. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 5. Repeat Violation: The license holder was cited for a similar violation in a correction order dated March 1, 2019, and an order for conditional license dated February 23, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain personnel records as required in this subdivision. You must correct the violations as described above. 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 10 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 Amani Health Care Services LLC a copy of the notification must also be provided to their legal representatives and case managers. While your license is on conditional status, you must provide written notification of the conditional status of your license to all prospective service recipients and their legal representatives and case managers prior to service initiation. The notification must include an offer to provide a copy of the Order of Conditional License upon request. Within 30 days from receipt of this Order, you must submit a copy of the notice and a list of all persons that received the notice to your DHS licensor. 2. Within 30 days of receiving this order, you must: · designate a staff person who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person 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 60 days of receiving this order, you must: · submit a written plan to your DHS licensor detailing how you will ensure the corrective action ordered in this order is completed; and · submit a written plan to your DHS 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 DHS licensor; and · submit the date to your DHS 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. 6. You may not add additional HCBS licensed services or settings to your license for the duration of the conditional license. 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 · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 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 Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: 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 take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for one year from that date. 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. · Home and community-based services 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 2. · 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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