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November 1, 2024 Mahamad Salah, Authorized Agent A Quality Care Inc. 7900 Excelsior Boulevard Suite 2320 Hopkins, Minnesota 55343 License Number: 1106025 (245D – HCBS) CORRECTION ORDER Dear Mahamad Salah: On September 3, 2024, a licensing review of A Quality Care Inc., located at 7900 Excelsior Boulevard Suite 2320, 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 (b). Violation: For one of one person whose record was reviewed (P1), the license holder did not establish an individual abuse prevention plan (IAPP) as required. The license holder maintained multiple documents in P1’s record that included assessments of potential risk areas for P1; however, the documents contained inconsistent information. Additionally, the license holder failed to include statements of specific measures, with specific actions, the program will take to minimize the risk of abuse within the scope or control of the licensed services. Corrective Action Ordered: Within 30 days of receiving this order, you must establish an IAPP for P1 that meets the requirements of this section. Additionally, you must maintain the IAPP in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation of health needs as required. The license holder was assigned responsibility for meeting P1’s health needs in P1’s support plan. The license holder failed to maintain documentation on how P1’s health needs would be met that included a description of the procedures the license holder would follow in order to provide medication assistance to P1. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation on how you will meet P1’s health needs that includes a description of the procedures you will follow in order to provide medication assistance to P1 and maintain this documentation in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet initial service planning requirements for intensive support services. a. While the license holder completed the assessments required in paragraph (b), clauses (1) through (3), the license holder failed to ensure these assessments produced information about P1 that described P1’s behaviors or symptoms. b. The license holder held P1’s initial planning meeting on April 19, 2024; however, the license holder failed to: · include P1’s case manager in this meeting; · determine opportunities to develop and strengthen personal relationships with other persons of P1’s choice in the community; · hold a discussion of how technology might be used to meet the person's desired outcomes; and · include a summary of this discussion in P1’s support plan addendum that included a statement regarding any decision that was made regarding the use of technology and a description of any further research that needed to be completed before a decision regarding the use of technology could be made. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise the assessments completed for P1 to ensure they produce information that describes P1’s behaviors or symptoms and maintain these assessments in P1’s service recipient record; · meet with P1 and their case manager to: o determine opportunities to develop and strengthen personal relationships with other persons of P1’s choice in the community; and o hold a discussion of how technology might be used to meet the person's desired outcomes; · maintain documentation of this meeting in P1’s support plan addendum that includes: o the opportunities to develop and strengthen personal relationships; and o a summary of the technology discussion that includes a statement about any decision 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop service outcomes and supports as required. The license holder failed to develop a service plan for P1 that documented the following supports and methods to be implemented to support P1 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being, within 10 working days of the initial planning meeting: · the methods or 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 outcome has 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 develop a service plan for P1 that documents the supports and methods required above for each of P1’s outcomes and maintain this service plan in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not inform and provide copies of policies and procedures as required. P1’s services were initiated on March 7, 2024. The license holder failed to inform and provide P1’s case manager with copies of the following policies and procedures affecting a person’s rights under section 245D.04 within five working days of service initiation: · grievance policy and procedure; · service suspension policy and procedure; · service termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy requirements. The license holder provided these to P1’s case manager on May 13, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one of three staff persons whose record was reviewed (SP3), the license holder did not provide annual training as required. The license holder failed to provide SP3 with annual training on the following topics: · orientation training in sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment according to section 245A.65, subdivision 3 including the program abuse prevention plan; · the safe and correct use of manual restraint on a n 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 · 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 receipt of this order, you must provide SP3 with training on the topics required above. Additionally, you must maintain documentation of this training in SP3’s personnel record according to the requirements in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: The license holder did not establish a written program abuse prevention plan (PAPP) as required. The license holder provided service to P1 at a location that was within the control of the license holder. The license holder failed to establish a written 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 Ordered: Immediately, you must: · establish a written PAPP for any location 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 to all persons receiving services at these locations; · maintain documentation of the orientation in each person’s service recipient record; and · provide all staff persons providing direct support to service recipient at these locations with orientation to the PAPP. 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. Krista Hastings, HCBS Licensor Licensing Division Office of Inspector General 651-431-4825
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