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December 16, 2024 CERTIFIED MAIL Makia Camara, Authorized Agent Angel Healthcare Staffing LLC 301 76th Avenue North Minneapolis, Minnesota 55444 License Number: 1098738 (245D – Home and Community-Based Services) ORDER OF CONDITIONAL LICENSE Dear Makia Camara: The Department of Human Services (DHS) is placing your license to provide at Angel Healthcare Staffing LLC, located at 301 76th Avenue North, Minneapolis, Minnesota, on conditional status for two years, beginning December 16, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Home and Community-Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On October 22, 2024, DHS licensors conducted a licensing review at your facility located at 301 76th Avenue North, Minneapolis, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Home and Community-Based Services, citing 14 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of persons served by the program. The licensing violations include: o Failure to provide program coordination, evaluation, and oversight by a designated coordinator and a designated manager; o Failure to develop and incorporate positive support strategies and person-centered planning; o Failure to meet the requirements for basic service planning and delivery; o Failure to provide persons served with an orientation to and an explanation of the service recipient rights: o Failure to include case managers with initial and ongoing service planning and delivery; o Failure to maintain service recipient records; and o Failure to provide required orientation and annual training to staff persons. · Chronicity: The license holder was non-compliant across many areas of licensed service delivery and identified violations were not isolated to one area of concern. Non-compliance was found in recordkeeping, service recipient service delivery, staff orientation and training, staff annual training, program coordination, program evaluation, program oversight, and policies and procedures. In addition, there were several repeat violations that the license holder failed to correct from their initial licensing review on December 5, 2019. o December 16, 2024 Conditional License (this order): 14 violations 8 repeat violations o November 21, 2024 Order to Pay a Fine: 1 Background Study Violation o December 19, 2019 Correction Order: 10 violations · Severity: Many of the violations that led to the Order of Conditional License relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Home and Community Based Services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination and Oversight Violations 1. Violation: The license holder did not meet the requirement for program coordination, evaluation, and oversight. a. The license holder identified SP4 as the designated coordinator. The license holder failed to ensure SP4 met the qualifications for the designated coordinator as stated in Minnesota Statutes, section 245D.081, subdivision 1, paragraph (b). SP4 did not have the education or experience as stated in this subdivision. In addition, the license holder failed to ensure SP4 preformed the required duties, including supervision, support and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; and · instruction and assistance to direct support staff implementing the support plan, including the failure to have an established process in which the designated coordinator determines competency of the person that has been delegated the responsibility to directly observe the service delivery activities to assess staff competency. The license failure to provide program coordination and oversight of the service provided is evidenced in citations 2 thought 14. b. The license holder identified SP4 as the designated manager. The license holder failed to ensure SP4 met the qualifications of the designated manager as stated in Minnesota Statutes, section 245D.081, subdivision 3. SP4 did not have the education or experiences required in this section. In addition, the license holder failed to ensure SP4 performed the required program management and oversight of the services provided by the license holder that included the following duties: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including periodic performance evaluations of the direct supports staff ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the service provided is evidenced in citations 2 through 14. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. Person Served Violations 2. Violation: For three of four persons whose records were reviewed (P1, P2 and P3), the license holder did not develop and review individual abuse prevention plans as required. a. The license holder failed to review P1’s individual abuse prevention plan (IAPP) with P1’s interdisciplinary team annually. In addition, the license holder failed to assess P1’s vulnerability of abuse. P1’s IAPP completed by the license holder documented that P1 was not susceptible to sexual abuse and self-abuse; however, the IAPP also stated P1 did not have the ability to be assertive in the area of sexual abuse and did not dress appropriately in the area of self-abuse. In addition, the license holder failed to include a statement of specific measures that would be taken to minimize the risk of abuse in these areas identified. The IAPP documented P1 was susceptible to financial abuse, however, there was no statement of the specific measures that would be taken to minimize the risk of abuse. b. P2’s services were initiated February 4, 2021. The license holder failed to develop an IAPP prior to or upon service initiation. P2’s IAPP did not have a date listed on the document. The license holder also failed to review P2’s IAPP with P2’s interdisciplinary team annually. In addition, P2’s IAPP stated P2 was not susceptible to abuse; however, the license holder stated during the licensing review that P2 was susceptible to abuse due to P2’s mental health. The license holder failed to develop an IAPP that contained an individualized assessment of: · the person’s susceptibility to abuse by other individuals, including other vulnerable adults; · the person’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. c. P3’s services were initiated on December 5, 2023. The license failed to develop an IAPP prior to or upon service initiation. The license holder developed P3’s IAPP on December 6, 2023. In addition, P3’s IAPP stated that P3 was not susceptible to abuse in any area; however, the support plan for P3 provided by the license holder identified numerous areas of susceptibility for abuse. The license holder failed to develop an IAPP that contained an individualized assessment of: · the person’s susceptibility to abuse by other individuals, including other vulnerable adults; · the person’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 3. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide service recipient rights as required. a. The license holder failed to provide P1 and P2, or their legal representative, if any, with a written notice that identified the service recipient’s rights in subdivisions 2 and 3 and an explanation of those rights annually. b. The license holder failed to provide P3 or their legal representative if applicable, with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 4. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for service planning and delivery as required. The license failed to meet person centered planning and delivery requirements for P1, P2, and P3 by failing to develop a support plan addendum that identified: · the person’s needs, interests, and preferences; · what is important to the person, and · preferences for when, how, and by whom direct care services would be provided. Statute Violated: Minnesota Statute, section 245D.07, subdivision 1a, paragraph (b). 5. Violation: For one person whose record was reviewed (P3), the license holder did not meet service initiation requirements for a basic service as required. The license holder failed to, within 60 calendar days of service initiation, review and revise as needed P3’s preliminary support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 6. Violation: For four persons whose records were reviewed (P1 – P4), the license holder did not maintain service recipient files as required. a. The license holder failed to maintain daily progress notes for P1, P2, and P3’s in their service recipient records. b. The license holder failed to document an admission form that included the name, address, and telephone number of the person's legal representative, if any, and a primary emergency contact, the case manager, and family members or others as identified by the person or case manager for P2 and P3. c. The license holder failed to maintain a service recipient record for P4. The license holder stated they served P4 for a short period of time: however, the license holder could not remember the name of P4 and could not produce a record for P4. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 7. Violation: For two persons whose record was reviewed (P2 and P3), the license holder did not provide policies and procedures as required. The license holder failed to provide the following policies and procedures that affect a person’s rights to P2 and P3’s case managers within five working days of service initiation: · grievance policy; · service suspension policy; and · service termination policy. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 8. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not develop positive support strategies as required. The license holder failed to identify and incorporate positive support strategies for P1, P2 and P3 in writing to an existing service plan. The positive support strategies were to be evaluated at minimum every six months. Statute Violated: Minnesota Rule 9544.0030, subpart 1. Health Service Needs 9. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not document how health needs would be met as required. a. P1 and P2’s support plan addendums stated the license holder would assist with doctor appointments. The license holder failed to document what assistance P1 and P2 needed with doctor appointments and how the license holder would assist P1 and P2 in getting to doctor appointments. b. P3’s support plan stated the license holder would assist P3 with doctor appointments. The license holder failed to document what assistance P3 needed with doctor appointments and how the license holder would assist P3 getting to doctor appointments. In addition, the support plan documented the license holder would assist in monitoring P3’s health conditions; however, the license holder failed to document how these health conditions would be monitored. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Staffing Standards 10. Violation: The license holder did not meet staff standards as required. During a conversation with DHS licensors at the time of the review, the license holder stated that after the initial introduction was made between the staff person and the person to whom the staff person was providing direct care services, the license holder did not provide any ongoing staff supervision. Additionally, the license holder was unable to answer general questions regarding the service recipients support needs and minimal information was found in the service recipient records. The license holder failed to provide the level of direct service support staff supervision, assistance, and training necessary: · to ensure the health, safety, and protection of rights of each person; and · to be able to implement the responsibilities assigned to the license holder in each person's support plan or identified in the support plan addendum, according to the requirements of this chapter. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 1. 11. Violation: For three of three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation training as required.
· 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; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 12. Violation: For three persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide SP1, SP2 and SP3 orientation to the individual service recipient needs prior to staff providing unsupervised direct contact services. The license holder documented a date this orientation was provided and stated that they had the staff person read the documents that were in the persons’ service recipient record; however, based on the review of the persons’ service recipient records, it was determined that the records were deficient of the required of the required information that would be needed to provide the required information that would be needed to provide the required orientation to the individual’s service recipient needs. Additionally, SP2 provided unsupervised direct care services to multiple people in the program. Although the license holder documented a date for which SP2 received orientation to individual service recipient needs, the date was prior to the service initiation for multiple persons to whom SP2 provided direct care services. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a. Repeat Violation: In a Correction Order that DHS issued on December 19, 2019, you were previously found in violation of this same statute. 13. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training as required. The license holder failed to provide SP2 and SP3 with annual training on the following required topic areas: · data privacy requirements according to Minnesota Statutes, section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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 Minnesota Statutes, 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 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, and 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; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · basic first aid. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. Policy and Procedures 14. Violation: The license holder failed to enforce policies and procedures as required in this subdivision. The license holder failed to enforce their policy and procedure for data privacy. P2’s policy receipt signature page that was signed by P2 had the name of another service recipient at the top of the document. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 1. Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 60 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with Home and Community Based Services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Additionally, DHS will not approve a request to add additional Home and Community Based Services to your license from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the Home and Community Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, other than SP4 who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP4 to provide program management and oversight of the services provided by the license holder; and · submit this staff person’s name and qualifications to your licensor for review and approval. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 45 days of receiving this order, you must: · submit a written plan detailing how you will ensure the corrective action ordered in this order is completed; and · submit a written plan to your DHS licensor detailing how you will audit all participant and personnel records for compliance with all applicable rules and statutes. 4. Within 60 days of receiving this order, you must: · develop and maintain a training curriculum for each training topic required to be provided to staff persons; · complete the audit of all participant and personnel records according to your written plan; · submit the results of the audit to your licensor; and · submit the date to your licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 5. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Admission of any new participant during the duration of the conditional license is only allowed with prior approval from DHS. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all Home and Community Based Services laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community Based Services are required to follow Minnesota Statutes, chapters 245A, 245C, and 245D and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, Supervisor, at 651-431-6591. Sincerely,
Brittany Raddatz, Unit Supervisor Licensing Division Office of Inspector General
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