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June 13, 2024 Cedric Key, Authorized Agent Key 360 Support Services LLC 4124 Quebec Avenue North, Suite 101 Minneapolis, MN 55427 License Number: 1090600 (Home and Community-Based Services) License Number: 1096143 (Community Residential Setting) License Number: 1097300 (Community Residential Setting) CORRECTION ORDER AND NONCOMPLIANCE WITH TERMS OF A CONDITIONAL LICENSE Dear Cedric Key: On December 16, 2022, the Commissioner of the Department of Human Services (DHS) issued an Order of Conditional License to Key 360 Support Services, LLC located at 4124 Quebec Avenue North, Suite 101, Minneapolis, Minnesota. On May 9, 2024, a licensing review of Key 360 Support Services LLC was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services (HCBS) to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D and the terms of the Order of Conditional License issued on December 16, 2022. As a result of this licensing review, a Correction Order and Noncompliance with the Terms of a Conditional License is being issued. A. Reason for Correction Order and Noncompliance with the terms of Conditional 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. Service Recipient Violations 1. Citation: Minnesota Statutes, section 245D.04, subdivision 3 Violation: For one person whose record was reviewed (P3), the license holder did not ensure the exercise and protection of the service recipient rights as required. The license holder failed to ensure and exercise the following service related rights for P3: · engage in chosen activities; · access to personal possessions at all times; · have use of and free access to common areas in the residence; and · have freedom and support to access food and potable water at any time. The license holder maintained documentation in P3’s daily log notes numerous restrictions of P3’s service recipient rights, including the following: · a daily log note from February 29, 2024 stated, P3 “tried refusing veggies but writer told [P3] that [P3] couldn’t have a cupcake for snack if [P3] didn’t eat the veggies;” · a daily log note from September 23, 2023 stated that P3 expressed dislike for what was being made for dinner. Staff documented, “Writer told [P3] that [s/he] wouldn’t be getting a snack if [s/he] didn’t eat their dinner.” · a daily log note from February 16, 2024 stated, “When staff woke up at 6am, [P3] was awake with the TV on. Staff told [P3] it was too early for TV;” · a daily log note from February 16, 2024 stated, “[P3] wanted to get up at 7:15am. Staff told [P3] it was too early to get up;” · a daily log note from March 1, 2024 stated that staff asked P3 if P3 wanted to “try out [P3]’s new bag for work.” Staff explained to P3 that P3 should only put items needed for work into the bag. P3 had started putting unnecessary items into the bag. “Writer grabbed the new bag and started taking everything out,” “Writer went to lock the bag in the car until [P3] forgot about it.” This escalated into physical aggression towards staff and a housemate and a physical intervention of P3 by staff. Corrective Action Ordered: Immediately upon receiving this order, you must ensure the exercise and protection of the service recipient rights for all people receiving services in your program. Within 30 days of receiving this order, you must retrain all staff persons on the service recipient rights and provide an explanation of those rights. You must maintain documentation of this training in each staff person’s personnel file. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.06, subdivision 5. Violation: For one person whose record was reviewed (P3), the license holder utilized the use of prohibited procedure. The license holder failed to ensure that the protection standards for P3 when on February 1, 2024, a staff person implemented the prohibited procedure of deprivation of the normal goods and services. The daily log note maintained by the program for P3 on this date, stated that P3 was not allowed to have a “treat” after dinner due to P3’s earlier behavior. Corrective Action Ordered: Immediately upon receiving this order, you must discontinue the use of prohibited procedures. Within 30 days of receiving this order, you must retrain all staff persons on the use of prohibited procedures. You must maintain documentation of this training in each staff persons personnel file. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.061, subdivisions 5 through 8. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not report the use of a manual restraint as required. Daily log notes maintained by the program for P2 and P3 documented multiple emergency use of manual restraints (EUMR) that had been implemented for P2 and P3. The incidents occurred on March 4, 2024, March 29, 2024, and February 1, 2024. The license holder failed to submit a behavior intervention reporting form (BIRF) related to these incidents as required. Corrective Action Ordered: Within 10 days of receiving this order, you must review the last 12 months of daily log notes for all persons receiving services in your program. You must complete an incident report and use the behavior intervention reporting form to report any emergency use of manual restraints, including the ones mentioned above. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. . 4. Citation: Minnesota Statutes, section 245D.081, subdivision 1. Violation: The license holder did not ensure program coordination and evaluation of services as required. The license holder failed to ensure the: · coordination of service delivery and evaluation for each person served by the program as identified in subdivision 2; and · program management and oversight that included evaluation of the program quality and program improvement for services provided by the license holder as identified in subdivision 3. Evidence to support this violation can be found in violations one through three. The license holder failed to ensure oversight of the service delivery in order to maintain compliance with Minnesota Statute 245D and the Positive Supports Rule, as it related to service recipient rights, prohibited procedures, incident reporting requirements, and corrective action. Corrective Action Ordered: Throughout the duration of your conditional license, you must ensure that the designated manager and/or designated coordinator provide the oversight necessary to ensure the compliance of service delivery related to service recipient rights, prohibited procedures, emergency use of manual restraints, and any other requirements of 245D and the Minnesota Positive Support Rule. You must maintain weekly documentation of the review and evaluation of service delivery documents and any necessary retraining of staff persons. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. Corrective Action Required If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner 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 ATTN: 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.
Sincerely, Tiffany Solano, HCBS Licensor Licensing Division Office of Inspector General 651-431-6649
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