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May 1, 2024 Hussein Mohamed, Authorized Agent Living Hope LLC 5400 Opportunity Court Suite 110 Hopkins, MN 55343 License Number: 1104769 (245D – HCBS) CORRECTION ORDER Dear Hussein Mohamed: On March 14-15, 2024, a licensing review of Living Hope LLC, located at 5400 Opportunity Court Suite 110, Hopkins, MN, 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. Violation: The license holder did not establish written program abuse prevention plans (PAPP) as required. The license holder provided crisis respite services , at locations that were within the control of the license holder. The license holder failed to establish written PAPPs that assessed the population, the physical plant, and the environment within the control of the license holder and the location where licensed services were provided. Corrective Action Ordered: Immediately, you must: · establish written PAPPs for locations where licensed services are provided and are within your control; · post the PAPP in a prominent location in the program; · provide an orientation to the PAPP for clients receiving services at these locations; and · provide staff persons providing direct support to clients at these locations with an orientation to the PAPPs. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for medication administration as required. The license holder was assigned responsibility for medication administration for P1, P2 and P3. The license holder failed to maintain the following documentation in P1, P2 and P3’s medication administration records (MAR): · instructions on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the above information for P1, P2 and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not ensure that medication administration records were reviewed as required. The license holder failed to review P1, P2, and P3’s MARs to identify medication administration errors at a minimum of every three months. Corrective Action Ordered: Within 30 days of receiving this order, you must review P1, P2, and P3’s medication administration records from January 2024 through March 2024. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (a). Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the conditions for psychotropic medication administration as required. P1, P2, and P3 were prescribed psychotropic medications. The license holder failed to maintain documentation that includes a description of the target symptoms that each psychotropic medication is to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you maintain documentation of the target symptoms for each psychotropic medication for P1, P2, and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not meet the requirements for assessments and initial service planning as required for intensive services. a. The license holder failed to complete assessments which produced information about the P3 and P4’s overall strengths, functional skills, and abilities, and behaviors and symptoms. b. The license holder held a 45-day service planning meeting for P3; however, the license holder failed to determine the following: · 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 the person's desired outcomes; · the person's preferences for 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; · 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 continuity of care and coordination of services for the person; and · a discussion of how technology might be used to meet the person's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete assessments for P3 and P4, including the requirements stated above; and · meet with P3, P3’s legal representative and P3’s case manager to determine the above. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For three persons whose records were reviewed (P3, P4 and P6), the license holder did not develop a service plan that documents the service outcomes and supports as required. a. The license holder developed outcomes for P3, P4 and P6; however, the license holder failed to document one or more of the following supports and methods to be implemented to support P3, P4, and P6 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being: · methods of actions that will be used to support the person and to accomplish the service outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style. · the measurable and observable criteria for identifying when the desired outcomes had been achieved and how data will be collected; § the projected starting date for implementing the supports and methods and the date by which 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. Corrective Action Ordered: Within 30 days of receiving this order, you must document the supports and methods used to support P3, P4 and P6, including the requirements above. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g). Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not meet the requirements for service plan review and evaluation as required. a. P3’s support plan addendum documented that the license holder would complete quarterly progress reports. While the license holder provided semi-annual progress reports, the license holder failed to provide quarterly progress reports for P3. b. The license holder failed to summarize, in a report, P4’s status and progress toward achieving the identified outcomes, including: · making recommendations; and · identifying the rationale for changing, continuing, or discontinuing implementation of supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a summary progress report for P4, including the requirements mentioned above. On an ongoing basis, you must maintain service planning documentation for all persons, as required in this subdivision. 8. Citation: Minnesota Statutes, Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P6), the license holder did not provide written or electronic copies of policies and procedures as required The license holder failed to inform P6’s case manager of the policies and procedures affecting P6’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: • grievance policy; • temporary service suspension policy; • service termination policy; • emergency use of manual restraints policy; and • data privacy policy. P6’s case manager received these on October 18, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three of three staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide orientation to program requirements as required. a. The license holder failed to provide SP1 with the following orientation training within 60 days of hire: · 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 or successor provisions, 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, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. These trainings were provided to SP1 at a later date. b. The license holder failed to provide SP2 and SP3 with the following orientation training within 60 days of hire: · 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 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: Within 30 days of receiving this order, you must provide the above training to SP2 and SP3. 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 me as soon as possible. Robert Romani, HCBS Licensor Licensing Division Office of Inspector General 651-431-3658
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