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January 24, 2024 Bhim Adikari, Authorized Agent Bhutanese Home Health Care Services 1901 Wagener Place Roseville, Minnesota 55113 License Number: 1100439 (245D – HCBS) CORRECTION ORDER Dear Bhim Adikari On September 28, 2023, a licensing review of Bhutanese Home Health Care Services located at 1901 Wagener Place, Roseville, 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 two of two persons whose records were reviewed (P1 and P2), the license holder did not provide an orientation to the internal and external reporting procedures of alleged and suspected maltreatment as required. a. P1’s services were initiated July 25, 2022. The license holder failed to provide orientation to internal and external reporting procedures of alleged and suspected maltreatment to P1 within 24 hours of admission. b. P2’s services were initiated November 6, 2021. The license holder failed to provide orientation to internal and external reporting procedures of alleged and suspected maltreatment to P2 and P2’s legal representative within 24 hours of admission. The license holder provided this orientation to P2 and their team March 4, 2022. 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 and P1’s legal representative; · submit documentation to your licensor that P1 received this information; · complete an audit of all service recipient records receiving services licensed under this chapter to ensure each person was provided with orientation to your internal and external reporting procedures or alleged or suspected maltreatment of vulnerable adults; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet requirements for an individual abuse prevention plan (IAPP) 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 include an individualized assessment of P1’s susceptibility to abuse by others and a statement of specific measures to be taken to minimize the risk of abuse to the person. P1’s IAPP states that P1 is not susceptible to abuse, however, this assessment was not consistent with information reviewed in P1’s record. Additionally, the license holder failed to review P1’s IAPP annually in 2023. b. The license holder failed to develop an IAPP as part of the initial service plan. The license holder also failed to include an individualized assessment of P2’s susceptibility to abuse by others and a statement of specific measures to be taken to minimize the risk of abuse to the person. P2’s IAPP states that P2 is not susceptible to abuse, however, this assessment was not consistent with information reviewed in P2’s record. Additionally, the license holder failed to review P2’s IAPP annually in 2023. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and revise P1’s IAPP to include a statement of the specific measures that would be taken to minimize the risk of abuse for each assessed area of risk of abuse; and · review and revise P2’s IAPP to include the specific measures the program will take to minimize the risk of abuse within the scope of each licensed service P2 receives; · audit the IAPPs for all persons served by the program and ensure all IAPPs include an individual assessment and statement of specific measures as required; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, Subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified 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 P1 with a written notice that identifies the service recipient rights and an explanation of those rights in 2023. b. The license holder failed to provide P2 and P2’s legal representative 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 2023. Corrective Action Ordered: Within 60 days of receiving this order you must: · provide P1, P2 and P2’s legal representative with written notice that identified the service recipient’s rights; · submit documentation that P1, P2 and P2’s legal representative received this information to your licensor; · complete an audit of all service recipient records to ensure each person and their legal representative were provided service recipient rights; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose record was reviewed (P1 and P2), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. a. The license holder failed to inform P1 and P1’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; and · emergency use of manual restraints policy. b. The license holder failed to inform P2, P2’s legal representative and P2’s case manager of the above-mentioned policies and procedures within five days of service initiation. The license holder informed and provided copies of the policies to P2 and their team on March 4, 2022. Corrective Action Ordered: Within 60 days of receiving this order, you must: · inform and provide copies of the above-mentioned policies and procedures to P1 and P1’s case manager; · submit documentation to your licensor that P1 and P1’s case manager received this information; · complete an audit all service recipient records to ensure each person, their legal representative and case manager were informed and provided copies of the above-mentioned policies; and · maintain documentation of this audit that includes notation of action taken to come into compliance. 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 two persons whose records were reviewed (P1 and P2), the license holder did not meet the service planning requirements for basic support services as required. a. The license holder failed to complete a preliminary support plan addendum for P1 within 15 calendar days of service initiation. Additionally, the license holder failed to review and revise, as needed, the preliminary support plan addendum within 60 days of service initiation to document the following: · how, when, and by whom services will be provided; and · the person responsible for overseeing the delivery and coordination of services. P1’s individualized home supports without training services was initiated July 25, 2022. In a document titled “Service Admission Checklist for Basic Services,” P1 required quarterly and annual written reports regarding the person’s progress or status; however, the license holder failed to provide written reports quarterly or annually. b. The license holder failed to complete a preliminary support plan addendum for P2 within 15 calendar days of service initiation. Additionally, the license holder failed to review and revise, as needed, the preliminary support plan addendum within 60 days of service initiation to document the following: · how, when, and by whom services will be provided; and · the person responsible for overseeing the delivery and coordination of services. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete a support plan addendum for P1 and P2 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; · write and provide a report regarding P1’s progress or status to the person and their team; · submit documentation of the completed support plan addendums and written report to your licensor; · complete an audit of service recipient records to ensure each person has a completed support plan addendum; · complete an audit of all service recipient records to determine what, if any, written reports are due or overdue; · if the audit determines that written reports are due or overdue, they must be written and provided to the appropriate persons, legal representatives, case managers, or teams; and · maintain documentation of these audits that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was assigned the responsibility for medication assistance. The license holder failed to maintain documentation on how P2’s health needs would be met, including a description of the procedures the license holder would follow to provide medication assistance. Corrective Action Ordered: within 60 days of receiving this order, you must: · document the above-mentioned information for P2; · complete an audit of all service recipient records to ensure that documentation is maintained on how the person’s health needs will be met, including a description of the procedures the license holder will follow, if responsibility for meeting the person’s health service need has been assigned to the license holder; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as require in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain documentation in the service recipient records as required. a. The license holder failed to maintain a signed statement in P2’s record authorizing the license holder to act in a medical emergency when the person’s legal representative, if any, cannot be reached or is delayed in arriving. b. The license holder failed to maintain progress or daily log notes in P1 and P2’s record. Corrective Action Ordered: Within 60 days of receiving this order, you must maintain a signed statement in P2’s record authorizing the license holder to act in a medical emergency when the person’s legal representative cannot be reached or is delayed in arriving. Immediately, you must start maintaining progress notes in P1 and P2’s records. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Rules, part 9544.0030, subpart 1 Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate positive support strategies as required. The license holder failed to incorporate, in writing, positive support strategies to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Within 60 days of receiving this order, you must: · document the positive support strategies for P1 and P2 as required in this subpart; · complete an audit of service recipient records to ensure each person has positive support strategies that are written into an existing treatment, service, or other individual plan; · maintain documentation of this audit that includes notation of action taken to come into compliance; and · 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. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. The license holder failed to provide SP1 and SP2 with the following orientation training: · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · the person’s coordinated service support plan or coordinated service support plan addendum as it relates to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve an understanding of the person as a unique individual and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order you must: · provide SP1 and SP2 with the above mentioned required training; · submit documentation showing SP1 and SP2 received the training to your licensor; · complete an audit of personnel records to ensure each staff person received orientation training as required; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), 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. The license holder failed to provide SP1 with annual training as required in the following areas: · 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; · sections 245A.65, 245A.66, and 626.557 and chapter 260E, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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; · basic first aid; 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: Within 60 days of receiving this order you must: · provide SP1 with the above mentioned required training; · submit documentation showing SP1 received the training to your licensor. complete an audit of personnel records to ensure each staff person received annual training as required; and · maintain documentation of this audit that includes notation of action taken to come into compliance. On an ongoing basis, you must maintain compliance 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 (SP3) 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 10. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person other than SP3, 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 10. 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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 me as soon as possible. Nicole Riley, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-3657
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