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December 20, 2024 Mohamud Mohamed Better Living Services LLC 6191 Somersby Court North West Rochester, Minnesota 55901 License Number: 1111833 (245D – HCBS) CORRECTION ORDER Dear Mohamud Mohamed: On October 18, 2024, a licensing review of Better Living Services LLC, located at 6191 Somersby Court North West, Rochester, 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 2. Violation: For one of two persons whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder developed an IAPP for P1 that indicated P1 had a susceptibility to physical and self abuse; however, the license holder failed to develop an IAPP that included a statement of measures that would be taken to minimize the risk of physical and self abuse to P1. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s IAPP to include measures and specific actions the program will take to minimize the risk of abuse within the scope of licensed services. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide a written notice of the service recipient rights as required. P2’s services were initiated on August 22, 2024. The license holder failed to provide P2’s legal representative with a written notice that identified the service recipient rights 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 P2’s legal representative with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights; and · maintain documentation of P2’ or P2’s legal representative’s receipt of a copy and an explanation the rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraphs (b). 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 a description of the procedures the license holder will follow in order to provide medication assistance. Corrective Action Ordered: Within 30 days of receiving this order, you must document the description of the procedures the license holder will follow in order to provide medication assistance for P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain service recipient records as required. a. The license holder failed to maintain progress or daily log notes recorded by the program in P1 and P2’s record. b. The license holder failed to maintain documentation to a show a signed statement for P2 authorizing the license holder to act in a medical emergency when the person’s legal representative cannot be reached or is delayed in arriving. Corrective Action Ordered: Immediately upon receiving this order, you must: · begin recording and maintaining progress or daily log notes in the service recipient records for all person’s receiving services in your program; and · maintain documentation to a show a signed statement for P2 authorizing the license holder to act in a medical emergency when the person’s legal representative cannot be reached or is delayed in arriving. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not provide written or electronic copies of policies and procedures as required. P1 and P2’s services were initiated August 22, 2024. The license holder failed to inform P1 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; · service suspension · service termination policy · emergency use of manual restraints policy; and · data privacy. The license holder informed and provided copies of these policies to P1 on September 24, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the above-mentioned policies and procedures to P1’s case manager, P2 and, P2’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for positive support strategies as required. The license holder failed to develop positive support strategies for P1 and P2 and implement the positive support strategies in writing into an existing treatment, service, or other individual plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and implement positive support strategies in writing for P1 and P2, according to the standards in part 9544.0030, subparts 2, 3, and 4; and · at least every six months, evaluate with the person whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not obtain a written acknowledgement from P2’s legal representative when the license holder informed P2’s legal representatives of the license holder’s policy on the emergency use of manual restraint as required. The license holder failed to obtain a written acknowledgment from P2’s legal representatives indicating that P2’s legal representatives had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, section 245D.04. Corrective Action Ordered: Immediately, you must obtain a written acknowledgement from P2’s legal representative that P2’s legal representative was notified of your policy on the emergency use of manual restraint. On an ongoing basis, you must maintain compliance as required in this part. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of one staff person whose record was reviewed (SP1), the license holder did not provide orientation to mandated reporters as required. SP1 began providing direct contact services on August 22, 2024. The license holder failed to provide SP1 orientation on vulnerable adult maltreatment reporting, maltreatment to minors reporting, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours first providing direct contact. The license holder provided SP1 with this training on August 29, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.081, subdivision 2 and 3. Violation: The license holder did not designate a designated coordinator and a designated manager who is responsible for coordination and evaluation of individual service delivery as required. a. The license holder failed to provide a designated coordinator that provided supervision, support and evaluation of activities that include: · oversight of the license holder's responsibilities assigned in the person's support plan and the support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. The designated coordinator may delegate the direct observation and competency assessment of the service delivery activities of direct support staff to an individual whom the designated coordinator has previously deemed competent in those activities; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder failed to provide a designated manager to provide program management and oversight of the services provided by the license holder that included: · 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 the program implements corrective action identified as necessary by the program following review of incident and emergency reports according to the requirements in section 245D.11, subdivision 2, clause (7). An internal review of incident reports of alleged or suspected maltreatment must be conducted according to the requirements in section 245A.65, subdivision 1, paragraph (b); · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress toward accomplishing outcomes 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; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Corrective Action Ordered: Within 60 days of receiving this order, you must submit the following to your licensor: · the name of the person or persons that you have identified to perform the duties of the designated coordinator and the designated manager; and · the qualifications of your designated coordinator and designated manager according to Minnesota Statutes, section 245D.081, subdivisions 2 and 3. You must verify and document their competence according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3. On an ongoing basis, you must maintain compliance as required in these subdivisions. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide the following orientation to SP1 with 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 as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving of this order, you must ensure SP1 has reviewed and received instruction on the requirements stated above for each service recipient they are providing direct support services to. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (b). Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain personnel records as required. The license holder failed to maintain documentation of the following in SP1’s personnel record: · orientation and training, including the number of hours per subject area; and · the date of SP1’s first supervised direct contact with a person served by the program, and the date of first 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 tammi.mitei@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: Tammi Mitei 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. Tammi Mitei, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6341
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