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December 19, 2024 Ilyas Abdikadir, Authorized Agent One Family Care LLC 1751 County Road B West Suite 101 Roseville, Minnesota 55113-4037 License Number: 1103254 (245D – HCBS) CORRECTION ORDER Dear Ilyas Abdikadir: On September 4, 2024, a licensing review of One Family Care LLC, located at 1751 County Road B West Suite 101, Roseville, 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 1. Violation: For two of three persons whose records were reviewed (P1 and P3), the license holder did not provide an orientation to the internal external reporting procedures of alleged or suspected maltreatment of vulnerable adults or alleged or suspected maltreatment of minors within 24 hours of admission. a. P1 received multiple services from the license holder. The license holder failed to provide P1 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission when the license holder initiated a service on November 1, 2021. b. P3’s service initiation for Individualized Home Supports with family training and respite was on August 6, 2023. The license holder failed to provide P3’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors within 24 hours of service initiation for either service. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults; · provide P3’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors; · audit all persons served records to ensure the orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults or maltreatment of minors has been provided; and · submit the results of the audit 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. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) 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 failed to develop an IAPP for P1 and P2 as part of the initial service plan prior to or upon service initiation. b. The license holder failed to review P2’s IAPP at least annually. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s IAPP with P2’s interdisciplinary team and maintain documentation of the review in P2’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), 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 a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation when the license holder initiated a new service on November 1, 2021. b. The license holder failed to provide P1 and P2’s legal representative with a written notice annually. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 and P2’s legal representative with a written notice that identifies the service recipient rights and an explanation of those rights. On an ongoing basis, you must maintain compliance as required. 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 health needs would be met as required. P2’s support plan assigned the license holder responsibility for meeting P2’s health needs. The license holder failed to maintain documentation on how the person’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication setup, assistance, or administration according to this chapter; · monitor health conditions according to written instructions from a licensed health professional; · assist with other health service appointments; and · use medical equipment, devices, or adaptive aides or technology safely and correctly according to the 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.06, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not meet all the requirements for safeguarding and handling a person’s funds and property as required. The license holder assisted P2 with the safekeeping of funds. The license holder obtained written authorization from P2’s legal representative and case manager on July 24, 2021, however, the license holder failed to obtain authorization on an annual basis. Additionally, the license holder failed to implement the preferences surveyed on July 24, 2021, when the license holder failed to provide annual statements to P2’s legal representative and case manager that itemized receipt and disbursements of funds or other property. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain annual authorization from P2’s legal representative for safekeeping funds and property; and · survey, document, and implement the preferences of P2’s legal representative and case manager for frequency of receiving a statement that itemized receipts and disbursements of funds or other property. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services. Regarding P1 and P3, the license holder failed to: · complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation; · complete assessments in the following areas before the 45-day planning meeting: o the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; o the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and o the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. o assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms. · meet with the person, the person's legal representative, the case manager, and other members of the support team or expanded support team within 45 days of service initiation to determine: o the scope of the services to be provided to support the person's daily needs and activities; o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; o the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; o whether the current service setting is the most integrated setting available and appropriate for the person; o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; § A discussion of 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. The license holder completed these assessments for P1 on April 12, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P3, P3’s legal representative and P3’s case manager to determine the above mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required. The license holder failed to document the following information in P1 and P3’s current supports and methods for current outcomes: · 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 above supports and methods for the intensive service initiated on November 1, 2021; · develop a service plan for P3 that documents the above supports and methods; · audit all intensive service plans to ensure that supports and methods are developed; and · submit the results of the audit to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for service plan review and evaluation as required. P1’s support plan addendum required annual service planning and support team meetings. The license holder failed to participate in annual service planning and support team meetings in 2022 and 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not maintain documentation of service recipient records as required. a. The license holder failed to maintain progress review reports for P3. b. The license holder failed to obtain a signed statement authorizing the license holder to act in a medical emergency when P3's legal representative if any, cannot be reached or is delayed in arriving. Corrective Action Ordered: Within 30 days of receiving this order, you must: · start maintaining progress review reports in P3’s records; and · obtain a signed statement from P3’s legal representative authorizing the license holder to act in a medical emergency. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not inform and provide copies of policies and procedures as required. The license holder failed to inform and provide P2’s legal representative, P2’s case manager, P3’s case manager, and P3’s legal representative of the following policies and procedures that affect a person’s rights within five working days of service initiation: · grievance policy; · service suspension; · service termination; · emergency use of manual restraints; and · data privacy. Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the policies mentioned above to P2’s legal representative, P2’s case manager, P3’s case manager, and P3’s legal representative; · audit all persons served records to ensure the above mentioned policies have been provided; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not incorporate positive support strategies and person centered planning as required. Regarding P2 and P3, the license holder failed to evaluate with P2 and P3 identified positive support strategies at least every six months. Corrective Action Ordered: On an ongoing basis, you must evaluate with the person, at least every six months, whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. 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 lacey.l.walsvik@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: Lacey Walsvik 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 ATTN: Legal Unit Licensing Division PO Box 64242 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. Lacey Walsvik, HCBS Licensor Licensing Division Office of Inspector General 651-431-3667
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