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December 17, 2024 Nathan Xiong SmartChoice Home HealthCare LLC 11085 James Curve Woodbury, MN 55129 License Number: 1111380 (245D – HCBS) CORRECTION ORDER Dear Nathan Xiong, On December 2, 2024, a licensing review of SmartChoice Home HealthCare LLC, located at 2353 Rice Street, Suite 139, Roseville, MN, 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 three of three persons whose records were reviewed (P1, P2, and P3), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1, P2, and P3 as part of the initial individual program or service plan. Additionally, the license holder failed to review P1, P2, and P3’s IAPPs at least annually with their interdisciplinary teams. Corrective Action Ordered: Within 30 days of receiving this order, you must develop an IAPP for P1, P2, and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide P1, P2, and P3 and their legal representatives, if applicable, a written notice that identified the service recipient rights, and an explanation of those rights within five working days of service initiation and annually thereafter. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P2, and P3 and their legal representatives, if applicable, 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 in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not meet service planning requirements for basic support services as required.
The license holder failed to complete a preliminary support plan addendum based on P1, P2 and P3’s support plans within 15 calendar days of service initiation. Additionally, the license holder failed to review and revise the preliminary support plan addendum within 60 calendar days 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. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a preliminary support plan addendum for P1, P2, and P3 based on their support plans. On an ongoing basis, you must maintain compliance as required in this subdivision.
4. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not maintain service recipient records as required. The license holder failed to maintain the following information for P1, P2 and P3: · an admission form signed by the person or the person’s legal representative that included: o identifying information, including the person’s name, date of birth, address, and telephone number; o 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; · service information, including service initiation information, documentation verifying that services have been provided as identified in the support plan or support plan addendum according to paragraph (a), and date of admission or readmission; · health information, including medical history, special dietary needs, and allergies; · the person's current support plan or that portion of the plan assigned to the license holder; · copies of the individual abuse prevention plan; · a record of other service providers serving the person when the person's support plan or support plan addendum identifies the need for coordination between the service providers, that includes a contact person and telephone numbers, services being provided, and names of staff responsible for coordination; · documentation of orientation to service recipient rights according to section 245D.04, subdivision 1, and maltreatment reporting policies and procedures according to section 245A.65, subdivision 1, paragraph (c); and · progress or daily log notes that are recorded by the program, and reports received from other agencies involved in providing service or care to the persons. Corrective Action Ordered: Immediately upon receiving this order, you must ensure the information detailed above is maintained in P1, P2, and P3’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.095, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not ensure staff persons had access to service recipient records as required. The license holder failed to ensure staff responsible for carrying out P1, P2, and P3’s support plan addendum had access to their records. Corrective Action Ordered: Immediately upon receiving this order, you must ensure staff persons carrying out the support plan or support plan addendum have access to the P1, P2, and P3’s records. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not inform and provide copies of the policies and procedures affecting their rights within five working days of service initiation. The license holder failed to inform and provide copies of the following policies and procedures affecting a person’s rights to P1, P2, and P3 and their case managers within five working days of service initiation: · grievance and complaint; · service suspension; · service termination. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not evaluate positive support strategies as required. The license holder failed to review and evaluate the identified positive support strategies with P1, P2, and P3 at a minimum of every six months. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Statutes, section 245A.66, subdivision 1. Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of minors as required. The license holder failed to maintain a maltreatment of minors reporting and internal review policy that included that an internal review would be completed within 30 calendar days when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. Corrective Action Ordered: Within 30 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. You must also submit your revised written policies to your licensor. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 2, paragraph 3. Violation: The license holder did not establish and maintain policies and procedures related to grievances as required. While the license holder maintained a policy and procedure titled, “Grievance Policy,” the license holder failed to include the address of the highest level of authority in the policy. The grievance policy that was submitted to DHS on July 22, 2024, did not identify the address of the person who is the highest level of authority. Corrective Action Ordered: Within 30 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. You must also submit your revised written policies to your licensor. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation training as required. The license holder failed to provide SP1 with orientation training in the following areas within 60 calendar days of hire: · the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location, access, and staff responsibilities related to the implementation of those policies and procedures, including: o consumer grievance and complaint procedures; o consumer temporary service suspension; o consumer service termination; o prohibition of drug and alcohol use; and o emergency use of manual restraint; · basic first aid. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP1 with an orientation and training to the requirements identified above and maintain documentation of this training in their personnel record. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. 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 service recipient needs training as required. The license holder failed to provide SP1 and SP2 with the following training before having unsupervised direct contact with a person served by the program: · orientation to the individual service recipient needs; · the person’s support plan or support plan addendum; and · the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order, you must: · ensure SP1 and SP2 have reviewed and received instruction on the requirements identified above for each service recipient they are providing direct support services to; · complete an audit of all staff records providing direct support services licensed under this chapter to ensure the above stated training has been provided; · for staff persons who have not been provided this training, provide this training, and maintain documentation of completion as required in this chapter; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a) and (b). Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain personnel records for SP1 and SP2 that documented staff orientation and training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Additionally, the license holder failed to maintain documentation in SP1 and SP2’s personnel record or elsewhere, sufficient to determine the date of first supervised direct contact with a person served by the program, and the date of first unsupervised contact with a person served by the program. Corrective Action Ordered: Within 60 days of this order, you must: · maintain compliance with training records for SP1 and SP2’s personnel records; · complete an audit of all staff records providing direct support services licensed under this chapter to ensure the above stated personnel records are maintained. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.081. Violation: For one person whose record was reviewed (SP1), the license holder did not meet the requirements of program coordination, evaluation and oversight. a. The license holder failed to ensure the designated coordinator (SP1), provided coordination of service delivery and evaluation for each person served by the program. See citations 1 through 7 for the designated coordinator’s failure to provide supervision, support, and evaluation of activities including: · oversight of the license holder’s responsibilities assigned in the persons support plan and support plan addendum; · instruction and assistance to direct support staff implementing the coordinated service and support plan, including direct observation of service delivery sufficient to assess staff competency. b. The license holder failed to ensure that the designated manager (SP1) provided program management and oversight of the services provided by the license holder. See citations 1 through 7 for the designated manager’s failure to: · 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 (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; · evaluating the information identified in clauses (1) to (5) to develop, document, and implement ongoing program improvements. Corrective Action Ordered: Within 30 days of receiving this order, you must designate a staff person who is responsible for delivery and evaluation of services provided by the license holder. You must also designate a managerial staff person to provide program management and oversight of the services provided by the license holder. The same person may perform both functions if the work and education requirements are met in section 245D.081, subdivisions 2 and 3. You must submit the name(s) and qualifications of the staff person or staff persons who will act as the designated coordinator and designated manager to your licensor. 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 kelly.bosch@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: Kelly Bosch 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. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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