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October 11, 2024 Yusuf Omar, Authorized Agent Sunny Home Healthcare L.L.C 202 22 Avenue North Minneapolis, MN 55411 License Number: 1096146 (245D – HCBS) CORRECTION ORDER Dear Yusuf Omar: On August 12, 2024, a licensing review of Sunny Home Healthcare L.L.C, located at 202 22 Avenue North, Minneapolis 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 1, paragraph (c). Violation: For one of three persons whose records were reviewed (P1), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder provided multiple services to P1. P1’s service initiation for individualized home supports with family training and night supervision was May 4, 2022. P1’s service initiation for crisis respite was September 23, 2022. The license holder failed to provide P1’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment within 24 hours of admission for crisis respite. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1’s legal representative an orientation to the internal and external reporting procedures for alleged or suspected maltreatment; · submit evidence of this to your licensor; · audit all person served records to ensure the above has been completed; and · submit the audit result to your licensor. 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 (P3), the license holder did not meet the requirements for individual abuse prevention plans (IAPP) as required. The license holder assessed P3 as susceptible to physical abuse, however the license holder failed to include a statement of measures that would be taken to minimize the risk of abuse. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P3’s IAPP to include a statement of measures that will be taken to minimize the risk of abuse in all assessed areas; · submit evidence of this to your licensor; · audit all person served records to ensure the above has been included; and · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), 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 provided the service recipient rights to P1’s legal representative, however the license holder failed to include the service recipient right and explanation of the right of access to the person’s personal possessions at anytime, including financial resources. Additionally, the license holder failed to provide P1’s legal representative a written notice that identifies the service recipient rights and an explanation of the rights within five working days of service initiation for crisis respite. b. The license holder failed to provide a written notice that identified the service recipient rights annually to P2’s legal representative in 2020, 2021, and 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1’s legal representative a written notice that identifies and explains the service recipient rights, including the right of access to the person’s personal possessions at anytime, including financial resources; · provide P2’s legal representative a written notice that identifies the service recipient rights; · submit evidence of these to your licensor; · audit all person served records to ensure that a written notice and explaining of the service recipient has been provided, including the right of access to the person’s personal possessions at anytime, including financial resources ; and · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for health needs as required. The license holder failed to maintain documentation on how P1’s health needs would be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental and other health service appointments. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a description of the procedures the license holder will follow in order to assist with or coordinate medical, dental and other health service appointments for P1; · submit evidence of this to your licensor; · audit all person served records to ensure the above documentation has been maintained; · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (b) and (c). Violation: For one person whose record was reviewed (P1), the license holder did not meet the service planning requirements for basic support services as required. a. For P1, the license holder failed to complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation of crisis respite. b. The license holder failed to review and revise P1’s preliminary support plan addendum for night supervision to document when and by whom services would be provided. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a preliminary support plan addendum for P1 for crisis respite; · review and revise P1’s support addendum for night supervision to document when and by whom services will be provided; · submit evidence of these to your licensor; · audit all person served records to ensure a preliminary support plan has been completed; · audit all person served records to ensure all applicable support plan addendums have been reviewed and revised to document when and by whom services will be provided; and · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (d). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for initial service planning as required. The license holder held a meeting within 45-days of service initiation as required for P1, however the license holder failed to have a discussion 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: · a statement regarding any decision that is made regarding the use of technology; and · 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: · meet with P1, P1’s legal representative and P1’s case manager to determine the above; · submit evidence of this to your licensor; · audit all person served records to ensure the above has been determined; and · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for service outcomes and supports as required. For P1, the license holder failed to document the following supports and methods to accomplish outcomes: · the methods and actions that will be used to support the person and to accomplish 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 style; · the measurable and observable criteria for identifying when the desired outcomes has been achieved and how data will be collected; 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: · develop a support plan for P1 that documents the above mentioned supports and methods; · submit evidence of this to your licensor; · audit all person served records to ensure the above has been developed; and · submit the audit results to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (11). Violation: For three persons whose records were reviewed (P1-P3), the license holder did not maintain a service recipient record as required. For P1-P3, the license holder failed to maintain progress or daily log notes that are recorded by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a plan for maintaining progress or daily log notes; and · submit this plan to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not provide written or electronic copies of the policies and procedures affecting a person’s rights as required. a. The license holder failed to inform P1, P1’s legal representative, and P1’s case manager of the following policies and procedures affecting a person’s rights and provide copies of those policies and procedures, within five working days of service initiation for crisis respite: · grievance policy; · service suspension policy; · service termination policy; · emergency use of manual restraint policy; and · data privacy. b. The license holder failed to inform P3’s case manager of the following policies and procedures affecting 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; · emergency use of manual restraint policy; and · data privacy. Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the following policies and procedures to P1, P1’s legal representative, and P1’s case manager and P3’s case manager: o grievance policy; o service suspension policy; o service termination policy; o emergency use of manual restraint policy; and o data privacy. · submit evidence of this to your licensor; · audit all person served records to ensure the above has been provided; and · submit the audit results to your licensor. 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 of three staff persons whose records were reviewed (SP3), the license holder did not provide annual training as required. The license holder failed to provide the following training to SP3 annually in 2024: · 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; 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the above trainings to SP3; · submit evidence of this to your licensor; · audit all staff personnel records to ensure the above annual training has been provided; · submit the audit results to your licensor. 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 Robert.R.Romani@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: Robert Romani 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. Robert Romani, HCBS Licensor Licensing Division Office of Inspector General 651-431-3658
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