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November 21, 2024 Alicia Carey, Authorized Agent Olu’s Home Inc. 1315 Twelfth Avenue North Minneapolis, Minnesota 55411 License Number: 1068807 (245D – HCBS) CORRECTION ORDER Dear Alicia Carey: On June 4, 2024, through June 6, 2024, a licensing review of Olu’s Home Inc., located at 1315 12th Avenue North, Minneapolis, 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 245D.04, subdivision 1. Violation: For three of seven persons whose records were reviewed (P1, P3 and P5), the license holder did not provide a written notice that identified the service recipient rights as required. a. The license holder failed to provide P1 with a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights annually in 2023. b. The license holder failed to provide P3 and P5 with a written notice that identified the following service recipient rights annually in 2023 and 2024: · access to the person's personal possessions at any time, including financial resources; · have access to three nutritionally balanced meals and nutritious snacks between meals each day; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person's bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; · a setting that is free from hazards that threaten the person's health or safety; and · a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P3 and P5 with a written notice that identifies all of the service recipient rights identified in subdivisions 2 and 3, and an explanation of those rights. Additionally, you must maintain documentation of P3 and P5 or P3 and P5’s legal representative’s receipt of a copy and an explanation of these rights in P3 and P5’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P3), the license holder did not implement and document the restriction of a person’s rights as required. Through conversations with the license holder, it was determined P3 had a rights restriction that was implemented in April 2023. The license holder failed to document the rights restriction in P3’s support plan or support plan addendum including: · the justification for the restriction based on an assessment of the person’s vulnerability related to exercising the right without restriction; · the objective measures set as conditions for ending the restriction; · a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of the initial approval, at a minimum, or more frequently if requested by P3, P3’s legal representative, if any and case manager; and · signed and dated approval for the restriction from P3’s legal representative. The license holder completed documentation of P3’s rights restriction on April 4, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not maintain documentation on how the person’s health needs would be met. The license holder was assigned responsibility for medication administration in P4 and P5’s support plan addendum. The license holder failed to maintain documentation that included a description of the procedures the license holder would follow in order to administer a psychotropic PRN (as needed) medication to P4 and P5. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P4 and P5’s record that includes a description of the procedures you will follow in order to administer a psychotropic PRN medication to P4 and P5 according to this chapter. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a). Violation: For three persons whose records were reviewed (P2, P4 and P5), the license holder did not review medication administration records as required. The license holder was assigned responsibility for medication administration for P2, P4 and P5. The license holder failed to review P2, P4 and P5’s medication administration records 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 P2, P4 and P5’s medication administration record to ensure that the information maintained is current; · review for and identify medication administration errors; · based on the results of the review, you must report if a dose of medication was not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person to P2’s legal representative, P4’s legal representative, P5’s legal representative and P2’s case manager, P4’s case manager and P5’s case manager; · based on the review, you must develop and implement a plan to correct patterns of medication administration errors when identified; and · maintain a copy of these reviews in P2, P4’s and P5’s record as required in section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.06, subdivision 1, paragraph (e). Violation: For one person whose record was reviewed (P5), the license holder did not report serious injury of the person as required. Documentation maintained in P5’s record detailed a serious injury that occurred on January 16, 2024. The license holder failed to report this serious injury to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental Health and Developmental Disabilities as required under section 245.94, subdivision 2a, within 24 hours of the serious injury. Corrective Action Ordered: Immediately upon receipt of this order, you must report the serious injury for P5 that occurred on January 16, 2024, to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental Health and Developmental Disabilities. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For two person whose records were reviewed (P4 and P5), the license holder did not meet requirements for safeguarding and handling funds and property. At the time of the review, the license holder indicated they were responsible for safeguarding and handling P4 and P5’s funds. a. The license holder failed to obtain written authorization to do so from P4’s case manager within five working days of service initiation. b. The license holder failed to obtain written authorization to do so from P5 or P5’s legal representative and P5’s case manager annually. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain written authorization from P4’s case manager and P5 or P5’s legal representative and P5’s case manager to safekeep funds. Additionally, you must survey, document, and implement the preference of the P5 or P5’s legal representative and P4 and P5’s case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds or other property. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P4), the license holder did not provide services as assigned in their support plans and in compliance with the requirements of this chapter and the federal waiver plans. At the licensing review conducted on June 4-June 6, 2024, DHS licensors determined that the license holder failed to pay staff the higher wages consistent with the rates in the residential rate exception form approved for P4. Corrective Action Ordered: Immediately upon receiving this order, you must provide services as assigned in each person’s support plan and in compliance with the requirements of this chapter and the federal waiver plans. On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P4), the license holder did not meet service planning and delivery requirements for an intensive service as required. P4’s initial service planning meeting was held on January 18, 2024. The license holder failed to have a discussion of how technology might be used to meet the person’s desired outcomes and maintain a summary in P4’s support plan addendum of that discussion that included a statement regarding any decision that was 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 document the above identified information for P4. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop a service plan that documents the service outcomes and supports as required. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person-centered planning for P1 that documented the following: · 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 the data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would 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 P1 that documents the service outcomes and supports that includes the following: o the methods or actions that will be used to support P1 and to accomplish the service outcomes, including information about: · any changes or modifications to the physical and social environments necessary when the service supports are provided; · any equipment and materials required; and · techniques that are consistent with the person’s communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o 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 o the names of the staff or position responsible for implementing the supports and methods. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P2 and P5), the license holder did not meet requirements for service plan review and evaluation. a. Although the license holder did meet with P2, P2’s legal representative and P2’s case manager annually in 2023, the license holder failed to summarize P2's status and progress toward achieving one of the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting. b. The license holder failed to, at least once per year, in coordination with P5’s support team or expanded support team meet with P5, P5’s legal representative, P5’s case manager, and other people as identified by P5 or P5’s legal representative to discuss how technology might be used to meet the P5's desired outcomes and include a summary of this discussion in P5’s support plan addendum. c. The license holder failed to, at least once per year, in coordination with P5’s support team or expanded support team meet with P5, P5’s legal representative, P5’s case manager, and other people as identified by P5 or P5’s legal representative to discuss options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider and include a summary of this discussion in P5’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P5, P5’s legal representative, and other members of the support team to discuss: · how technology might be used to meet the P5's desired outcomes and include a summary of this discussion in P5’s support plan addendum; and · options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider and include a summary of this discussion in P5’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P4), the license holder did not maintain service recipient records as required. The license holder failed to obtain the following from P4’s legal representative: · a signed authorization to administer medications prior to the license holder administering medications to P4 and; · a signed statement authorizing the license holder to act in a medical emergency. The license holder obtained the authorizations from P4’s legal representative on January 18, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate the identified positive support strategies with P1 every 6 months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate the identified positive support strategies with P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For six of seven staff persons whose records were reviewed (SP1, SP3, SP4, SP5, SP6 and SP7), the license holder did not provide an orientation and training to the program abuse prevention plan (PAPP) and internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services as required. a. The license holder failed to provide SP1, SP3, SP4, SP5, SP6 and SP7 with an orientation to the license holder’s PAPP within 72 hours of first providing direct contact services and annually thereafter. b. The license holder failed to provide SP1 with an orientation to the license holder’s internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services. SP1 provided direct contact services on May 11, 2020. The license holder provided this orientation to SP1 on September 23, 2021. c. The license holder failed to provide SP5 with an orientation to the license holder’s internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services. SP5 provided direct contact services on January 13, 2023. The license holder provided this orientation to SP5 on February 12, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1, SP3, SP4, SP5, SP6 and SP7 with an orientation to the PAPP for each community residential setting at which they provide direct contact services. Additionally, you must maintain documentation of this orientation in their personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For six staff persons whose records were reviewed (SP1, SP3, SP4, SP5, SP6 and SP7), the license holder did not provide orientation and training as required. a. SP1 was hired on April 27, 2020. The license holder failed to ensure SP1 received orientation training on the following topics within 60 days of hire: · the job description and how to complete specific job functions, including responding to and reporting incidents as required under Minnesota Statutes, section 245D.06, subdivision 1 and following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures required under Minnesota Statutes, chapter 245D, including their location and access and staff responsibilities related to implementation of those policies and procedures; · data privacy requirements according to Minnesota Statutes, 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; o the license holder provided this orientation training to SP1 on July, 21, 2020; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied 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 and what constitutes the use of restraints, time out, seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 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. b. SP3 was hired on October 3, 2022. SP4 was hired on January 25, 2024. The license holder failed to ensure SP3 and SP4 received orientation and training on the following topics within 60 days of hire: · basic first aid; and o the license holder provided this to SP3 on February 3, 2023, and SP4 on April 26, 2024; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. SP5 was hired on January 11, 2023. The license holder failed to ensure SP5 received orientation and training to the following topics within 60 days of hire: · the job description and how to complete specific job functions; o the license holder provided this to SP5 on August 23, 2023; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 245D.04; and o the license holder provided this to SP5 on August 11, 2023; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. At the time of the licensing review, SP5 has not received this training from the license holder. d. SP6 was hired on October 17, 2023. SP7 was hired on February 26, 2024. The license holder failed to ensure SP6 and SP7 received orientation and training on 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 SP1, SP3, SP4, SP5, SP6 and SP7 with the above mentioned orientation trainings; · audit the records of all staff persons to ensure the required orientation training has been completed within 60 days; · based on the results of the audit, provide all required trainings to any staff persons that the license holder employs that is not in compliance; · submit you audit findings to this licensor; and · submit a detailed plan to your licensor of how you will maintain compliance in this subdivision moving forward. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide annual training as required. a. The license holder failed to provide SP1 with annual training on the following topics in 2023: · 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; · sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; b. The license holder failed to provide SP2 with annual training on the following topics in 2022 and 2023: · 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, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. The license holder failed to provide SP3 with annual training on the following topics in 2023: · 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, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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; 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: · audit the records of all staff persons to ensure the required annual training has been completed; · based on the results of the audit, provide all required trainings to any staff persons that the license holder employs that is not in compliance; · submit you audit findings to this licensor; and · submit a detailed plan to your licensor of how you will maintain compliance in this subdivision moving forward. 16. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For seven staff persons whose records were reviewed (SP1-SP7), the license holder did not maintain personnel records as required. The license holder failed to maintain documentation in SP1-SP7’s personnel record or elsewhere, sufficient to determine the date of the employee’s first supervised and unsupervised direct contact with a person served by the program. Corrective Action Ordered: 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 amber.n.nielsen@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: Amber Nielsen 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. Amber Nielsen, Home and Community-Based Services Licensor Licensing Division Office of Inspector General 651-431-3661
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