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December 5, 2024 Dia Yang, Authorized Agent Care4Everyone LLC 747 Milton Street North Saint Paul, Minnesota 55104-1530 License Number: 1085196 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Dia Yang: On October 15, 2024, a licensing review of Care4Everyone LLC, located at 747 Milton Street North, Saint Paul, 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.65, subdivision 1. Violation: For one of two persons whose records were reviewed (P2), 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 failed to provide P2 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must provide an orientation to the internal and external reporting procedures to P2. In addition, you must maintain documentation of this orientation as required in section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder failed to meet the requirements for abuse prevention plans. a. The license holder failed to assess P1’s risk of abuse. P1’s individual abuse prevention plan stated that P1 was not susceptible to abuse in the areas of self-abuse; however, this assessment was not consistent with information reviewed elsewhere in P1’s record. b. The license holder failed to assess P1’s risk of abuse. P2’s individual abuse prevention plan stated that P2 was not susceptible to abuse in all areas; however, this assessment was not consistent with information reviewed elsewhere in P2’s record. c. The license holder failed to include a statement of specific measures that the program would take to minimize the risk of abuse in all areas where P1 and P2 were assessed at being at risk of abuse in P1 and P2’s individual abuse prevention plan. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the individual abuse prevention plans for P1 and P2 to include the above mentioned information. 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 the person a written notice that identified the service recipient rights and an explanation of those rights as required. P1’s services were initiated on March 25, 2024. The license holder failed to provide P1 with a written notice that identified the service recipient’s rights in subdivisions 2 and 3 and an explanation of those rights within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with a written notice that identifies the service recipient rights and maintain documentation of receipt of this notice in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder failed to maintain documentation of how P2’s health needs would be met, including as applicable, a description of the procedures the license holder will follow in order to: · provide medication setup, assistance, or administration according to this chapter. Unlicensed staff responsible for medication setup or medication administration under this section must complete training according to section 245D.09, subdivision 4a, paragraph (d); · monitor health conditions according to written instructions from a licensed health professional; · assist with or coordinate medical, dental, and other health service appointments; or · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above-mentioned information for P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not provide copies of the policies and procedures as required. P2’s services were initiated on June 1, 2024. The license holder failed to inform P2 and P2’s case manager of the following policies and procedures that affect a person’s rights, and provide copies of those policies and procedures, within five working days of service initiation. · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy. Corrective Action Ordered: Within 30 days of receiving of this order, you must provide P2 and P2’s case manager with copies of the above mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to incorporate in writing positive support strategies to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Within 30 days of receiving this order, you must incorporate, in writing, positive support strategies for P1 and P2’s existing support plan. Additionally, you must evaluate the identified positive support strategies with P1 and P2 every 6 months. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning requirements for basic support services as required. The license holder failed to review and revise, as needed, the preliminary support plan addendum within 60 days of service initiation to document the following: · 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 document the above mentioned information in P2’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes for P1 and P2. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining progress or daily log notes for P1 and P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245A.04, subdivision 5. Violation: For one person whose record was reviewed (P2), the license holder did not ensure access to service recipient record as required. The license holder was unable to locate P2’s entire service recipient record at the time of this licensing review. The license holder failed to ensure the Commissioner had access to P2’s service recipient record. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual needs as required. The license holder failed to ensure that SP1 and SP2, before having unsupervised direct contact with a person served by the program, reviewed and received instruction on the following: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the above-mentioned orientation to SP1 and SP2; and · maintain documentation of this orientation in SP1’s and SP2’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide staff orientation as required. a. SP1 was hired April 2, 2024. SP2 was hired March 18, 2024.The license holder failed to provide orientation to the license holder’s current policies and procedures: · consumer grievance and complaint procedures; · consumer temporary service suspension; · consumer service termination; · prohibition on drug and alcohol use policy; and · emergency use of manual restraint. b. The license holder failed to provide SP1 and SP2 the following orientation training within 60 days of hire: · the job description and how to complete specific job functions including following safety practices established by the license holder as required in section 245D.06, subdivision 2; and · 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. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide orientation training to SP1 and SP2 on the above-mentioned topics. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain a personnel record for each employee that included: · date of hire; · documentation of staff qualifications; and · documentation of orientation, and training, including: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. Corrective Action Ordered: Within 30 days of receipt of this order, you must maintain a personnel record for SP1 and SP2 that includes the above-mentioned items. 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 ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 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. Kate Spenger, Human Services Licensor Licensing Division Office of Inspector General 651-431-5757
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