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May 21, 2024 Yasin Ali Siyad, Authorized Agent Oakley Care Inc 6109 Blue Circle Drive Suite 1000 Hopkins, Minnesota 55343 License Number: 1108406 (245D – HCBS) CORRECTION ORDER Dear Yasin Ali Siyad: On April 3 and 4, 2024, a licensing review of Oakley Care, located at 6109 Blue Circle Drive, Hopkins, 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 (a). Violation: The license holder did not establish and enforce a program abuse prevention plan (PAPP) as required. The license holder provided crisis respite services in a location that was within the control of the license holder. The license holder failed to develop a PAPP 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 Required: Immediately, you must: · develop a PAPP for locations where licensed services are provided and are within your control; · post the PAPP in a prominent location in the program; and · provide an orientation to the PAPP for clients receiving services at these locations. 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 one person whose record was reviewed (P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an individual abuse prevention plan (IAPP) for P2 as part of the initial service plan. P2’s service initiation date was March 12, 2022, and the license holder developed an IAPP for P2 on April 26, 2022. Corrective Action Required: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a). Violation: For one person whose record was reviewed (P3), the license holder did not review medication administration records as required. The license holder failed to ensure that the information maintained in P3’s medication administration record was regularly reviewed to ensure that the information was current and to identify medication administration errors. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P3’s medication administration record to ensure the information is current and to identify medication administration errors; · based on the review, develop and implement a plan to correct patterns of medication administration errors when identified; · conduct a review at a minimum of every three months, or more frequently as directed in the support plan or support plan addendum or as requested by the person; and · maintain documentation of all medication administration record reviews in P3’s record according to Minnesota Statutes, section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraphs (b) and (c). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not meet initial service planning requirements for a basic service as required. a. The license holder initiated a basic support service for P1 on January 9, 2023. The license holder failed to complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation. b. The license holder failed to review and revise, as needed, the preliminary support plan addendum for P1, P2, P3 and P4 within 60 calendar days of service initiation to document the following: · the services that will be provided, including 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 30 days of receiving this order, you must review and revise, as needed, P1, P2, P3 and P4’s preliminary support plan addendums as detailed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, 245D.071, subdivision 3, paragraph (b). Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not complete assessments as required. The license holder failed to complete assessments that produced information about P5 and P6 that described P5 and P6’s overall strengths, functional skills, and abilities. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the assessments for P5 and P6 to produce information about P5 and P6 that describes the person’s overall strengths, functional skills, and abilities. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P4), the license holder did not complete service planning for intensive support services as required. The license holder failed to meet with P4, P4’s legal representative, the case manager, other members of the support team or expanded support team, and other people as identified by P4 or P4’s legal representative within 60 calendar days of service initiation. P4 initiated services on April 28, 2023, and the license holder met with P4 and P4’s support team on July 7, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For four persons whose records were reviewed (P1, P4, P5 and P6), the license holder did not develop outcomes and supports as required. The license holder failed to document the following supports or methods for P1, P4, P5 and P6 that would be used to support the person to accomplish the service outcome: · the measurable and observable criteria for identifying when the desired outcome would be achieved; and · how data would be collected. Corrective Action Ordered: Within 30 days of receiving this order, you must revise P1, P4, P5 and P6’s outcome and supports to include the above information. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not complete service plan review and evaluation as required. The license holder failed to include the identified rationale for changing, continuing, or discontinuing implementation of supports and methods in reports that summarized P1 and P5’s progress toward achieving the identified outcomes. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (11). Violation: For four persons whose records were reviewed (P1, P2, P4 and P5), the license holder did not maintain records as required. The license holder failed to maintain progress or daily log notes recorded by the program in P1, P2, P4 and P5’s records. Corrective Action Ordered: Immediately, you must ensure that progress or daily log notes are being recorded for each service recipient by your program. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 4. Violation: The license holder failed to ensure access to service recipient records as required. The license holder failed to ensure that staff persons providing services to persons in the program had access to the information in the persons record relevant to carrying out the support plan and support plan addendum. Corrective Action Ordered: Immediately, you must ensure that staff persons providing services to persons in your program have access to the information in the person’s record that is relevant to carrying out the support plan and support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P2), the license holder did not inform and provide copies of the policies and procedures as required. The license holder failed to inform and provide copies of the following policies and procedures to P2’s case manager within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; and · emergency use of manual restraints. Corrective Action Required: Within 30 days of receiving this order, you must provide P2’s case manager with a copy of the above policies. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, Rule 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P6), the license holder did not evaluate positive supports strategies as required. The license holder failed to evaluate with P6 the identified positive supports strategies at least every six months to determine whether changes needed to be made to the positive support strategies used. The license holder reviewed P6’s positive support strategies in August 2022 and June 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three of four staff persons whose records were reviewed (SP1-SP3), the license holder did not provide annual training as required. 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, SP2, and SP3 the following annual training: · 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, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 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; · 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; · 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; · 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: Immediately, you must provide SP3 with annual training. 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 kristopher.oberg@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: Kristopher Oberg 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 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. Kristopher Oberg, HCBS Licensor Licensing Division Office of Inspector General 651-431-6589
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