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March 4, 2024 Adan Abdihoosh, Authorized Agent Limitless Health Care LLC 1250 Moore Lake Drive East Suite 214 Fridley, Minnesota 55432 License Number: 1110887 (245D – HCBS) CORRECTION ORDER Dear Adan Abdihoosh: On January 5, 2024, a licensing review of Limitless Health Care LLC, located at 1250 Moore Lake Drive East Suite 214, Fridley, 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 245D.04, subdivision 1. Violation: For three of three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide P1, P2, and P3 a written notice and explanation of the service recipient rights in subdivisions 2 and 3 that included the right to access to the person’s personal possessions at any time, including financial resources. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P2, and P3 a written notice that identifies the service recipient rights in subdivisions 2 and 3 and an explanation of those rights as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet the requirements for assessment and initial service planning for intensive support services as required. a. Regarding P1, whose services were initiated on February 21, 2023, the license holder failed to meet with P1 and P1’s case manager within 45 days of service initiation. The license holder met with P1 and P1’s case manager on July 14, 2023. Additionally, the license holder failed to include a discussion of how technology might be used to meet P1’s desired outcomes as part of the 45-day planning meeting. b. Regarding P3, whose services were initiated on September 23, 2023, the license holder failed to meet within 45 days of service initiation with P3 and P3’s case manager. The license holder met with P3 and P3’s case manager on November 16, 2023. Additionally, the license holder failed to include a discussion of how technology might be used to meet P3’s desired outcomes as part of the 45-day planning meeting. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet service planning requirements for the service outcomes and supports as required. a. The license holder failed to document the following information in P3’s service outcomes and supports: · the methods or actions that will be used to support the person and to accomplish the service outcomes; and · information about any changes or modifications to the physical and social environments necessary when the service supports are provided. b. The license holder failed to ensure the following in P1’s service plan: · the implementation of P1’s documented supports and methods; and · the collection of data that is measurable and observable for P1’s desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the service outcomes and supports listed above for P1 and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraphs (a), (b) and (g). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for service plan review and evaluation as required. The license holder failed to meet, in coordination with P1’s support team, with P1’s case manager and other people identified by the person to participate in a progress review meeting annually. Additionally, P1’s support plan required semi-annual progress reports. The license holder failed to provide progress reports for P1 semi-annually. Furthermore, the license holder failed to discuss with P1 and members of the support team about how technology might be used to meet P1’s desired outcomes at least once per year.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P1’s case manager and other people identified by the person to participate in a progress review meeting; · discuss with P1 and members of the support team about how technology might be used to meet P1’s desired outcomes; and · maintain documentation of this meeting in P1’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. 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 copies of policies and procedures as required.
P1’s services were initiated February 21, 2023. The license holder failed to inform P1’s case manager of and provide copies of the following policies and procedures withing five days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy requirements. The license holder informed and provided copies of the policies to P1’s case manager on March 17, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.10, subdivision 2. Violation: The license holder did not establish, enforce, and maintain policies and procedures as required in this section. The license holder established a policy titled, “Grievance Policy,” dated September 25, 2023; however, the license holder failed to provide the correct address of the highest level of authority in the program as required. Corrective Action Ordered: Within 30 days of receiving this order, you must establish the above stated policy to be in compliance with statutory requirements. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. Regarding SP1, who was hired on September 25, 2023, the license holder failed to provide the following orientation training within 60 days of hire: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; · 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; · 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. b. Regarding SP2, who was hired on February 20, 2023, the license holder failed to provide orientation training within 60 days of hire on the 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with the above mentioned training. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.081, subdivision 1, paragraph (a). Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not ensure the designated coordinator (SP3), provided program coordination and evaluation as required. The designated coordinator (SP3), failed to provide oversight of the license holder’s responsibilities assigned in P1 and P3’s support plans and support plan addendums. See citation 3 for details of these failures. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a written plan documenting how the license holder will ensure that the designated coordinator perform the required duties as identified in these subdivisions to maintain compliance across the program. 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 lacey.l.walsvik@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: Lacey Walsvik 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. Lacey Walsvik, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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