Minnesota

January 28, 2025

Angie Ouijiri

Circle of Life Home Care Anishinaabe

4100 Lexington Avenue North Suite 150

Shoreview, Minnesota 55126

License Number: 1074358 (245D – HCBS)

CORRECTION ORDER

Dear Angie Ouijiri:

On August 14, 2024, a licensing review of Circle of Life Home Care Anishinaabe, located at 4100 Lexington Avenue North Suite 150, Shoreview, 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, paragraph (b).

Violation: For six of seven persons whose records were reviewed (P1-P6), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required.

a. The license holder initiated individualized home supports with training for P1 on June 1, 2024. Although the license holder developed an IAPP for P1 that assessed the scope of homemaker services, the license holder failed to develop an IAPP for P1 that assessed the scope of individualized home supports with training.

b. The license holder failed to include an individualized assessment of P2’s susceptibility of abuse according to Minnesota Statutes section 626.557, subdivisions 14. The license holder developed an IAPP for P2 that documented that P2 was not susceptible to abuse or at risk of abusing other vulnerable adults; however, this assessment was not consistent with information reviewed elsewhere in the P2’s record.

c. The license holder developed IAPPs for P3, P4, P5, and P6 that indicated the person was susceptible to abuse; however, the license holder failed to include statements of the specific measures to be taken to minimize the risk of abuse to the person and other vulnerable adults.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· review and revise the IAPP for P1-P6 to meet the requirements of this subdivision. Additionally, you must provide the persons and their case managers, the opportunity to participate in the development of the IAPP;

· complete an audit of all person served records to ensure IAPPs have been developed according to Minnesota Statutes, section 245A.65, subdivision 3, paragraph (b); and

· for persons whose IAPPs are not developed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1).

Violation: For three persons whose records were reviewed (P1-P3), the license holder did not provide written notice of the service recipient rights 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. P1’s services were initiated on June 1, 2024. The license holder failed to provide P1 with a written notice that identified the service recipient rights and an explanation of those rights within five days of service initiation.

b. The license holder failed to provide P2 and P3 with a written notice that identified the service recipient rights and an explanation of those rights annually.

· The license holder provided P2 with service recipient rights in October 2022, and November 2023.

· The license holder most recently provided P3 with service recipient rights in March 2023.

Correction Action Ordered: Within 30 days of receiving this order, you must:

· provide P1 and P3 with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights;

· maintain documentation of P1 and P3’s receipt of a copy and explanation of the rights in P1 and P3’s record; and

· complete an audit of all person served records to ensure the above has been provided.

Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.05, subdivision 1 paragraph (b).

Violation: For six persons whose records were reviewed (P1, P3, P4, P5, P6 and P7), the license holder did not maintain documentation of how the persons’ health needs would be met as required.

a. The license holder was assigned the responsibility of meeting P1, P3, P4, P5, and P7’s health service needs according to each person’s support plan addendum. The license holder failed to maintain documentation on how P1, P3, P4, P5, and P7’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication assistance.

b. The license holder was assigned the responsibility of meeting P6’s health service needs according to P6’s support plan addendum. The license holder failed to maintain documentation on how P6’s health needs would be met, including a description of the procedures the license holder would follow in order to:

· provide medication assistance; and

· use medical equipment safely and correctly according to written instructions from a licensed health professional for P6.

Correction Action Ordered: Within 30 days of receiving this order, you must:

· document how P1, P3, P4, P5, P6 and P7’s health needs would be met, including a description of the procedures detailed above; and

· complete an audit of all person served records to ensure the above is documented.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3.

Violation: For six persons whose records were reviewed (P1-P5 and P7), the license holder did not complete basic support service planning as required.

a. The license holder failed to review and revise, as needed, P1-P5 and P7’s preliminary support plan addendum within 60 calendar 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.

b. P3, P4, and P7’s support plan addendums required the license holder to provide quarterly written reports to the person, their legal representatives, and their case managers. The license holder failed to provide written reports to P3, P4, P7, their legal representatives, and their case managers quarterly.

c. P2’s support plan addendum required semi-annual service planning and support team meetings, however, the license holder met with the support team on April 10, 2023, and November 28, 2023. The license holder failed to meet with the support team semi-annually as required.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· review and revise P1-P5 and P7’s support plan addendum to document how, when and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services; and

· complete an audit of all person served records to ensure the above has been completed.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For five persons whose records were reviewed (P2, P3, P4, P6, and P7), the license holder did not maintain a service recipient record as required.

The license holder failed to maintain progress or daily log notes recorded by the program in P2, P3, P4, P6, and P7’s record.

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. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b).

Violation: For five persons whose records were reviewed (P1, P3, P4, P5 and P7), the license holder did not provide written or electronic copies of policies and procedures as required.

a. The license holder failed to inform P1 and their case manager of the following policies and procedures, and provide copies of those policies and procedures, within five working days of service initiation, including:

· grievance policy;

· service suspension policy;

· service termination policy;

· emergency use of manual restraints policy; and

· data privacy.

b. The license holder failed to inform P3, P4, P5, P7 and their case managers of the following policies and procedures, and provide copies of those policies and procedures, within five working days of service initiation, including:

· grievance policy;

· service suspension policy; and

· service termination policy.

Corrective Action Ordered: Immediately upon receiving this order, you must:

· inform and provide copies of the policies and procedures affecting a person’s rights to P1, P3, P4, and, P1, P3, P4, P5 and P7’s case managers;

· complete an audit of all person served records to ensure these have been provided.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Rule, 9544.0030, subpart 1.

Violation: For three persons whose records were reviewed (P3, P4, and P7), the license holder did not meet requirements for positive support strategies as required.

The license holder failed to develop positive support strategies for P3, P4, and P7 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 P3, P4, and P7, 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 evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Rules, part 9544.0080, subpart 1.

Violation: For four persons whose record were reviewed (P3-P5, P7), the license holder did not obtain a written acknowledgement from P3-P5 and P7’s legal representative when the license holder informed P3-P5 and P7’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 P3-P5 and P7’s legal representatives indicating that P3-P5 and P7’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 P3-P5 and P7’s legal representative that P3-P5 and P7’s legal representative was notified of your policy on the emergency use of manual restraint. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part.

9. Citation: Minnesota Statutes, section 245D.09, subdivisions 4 and 4a.

Violation: For eight of eight staff persons whose records were reviewed (SP1-SP8), the license holder did not provide orientation as required.

a. The license holder failed to provide SP1 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· 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;

· the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, 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, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

b. The license holder failed to provide SP2 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), 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 section 245D.04;

· 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;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

c. The license holder failed to provide SP3 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· 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;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

d. The license holder failed to provide SP4 with the following orientation training within 60 days of hire:

· 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;

· basic first aid.

e. The license holder failed to provide SP5 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· 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;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

f. The license holder failed to provide SP6 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

g. The license holder failed to provide SP7 with the following orientation training within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· sections 245A.65 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. This orientation must be provided within 72 hours of first providing direct contact services according to section 245A.65, subdivision 3;

· 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;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

h. The license holder failed to provide SP8 with the following orientation training within 60 days of hire:

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· 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;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

i. The license holder failed to provide SP1-SP8 with an orientation to individual service recipient needs before having unsupervised direct contact with a person served by the program.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· provide SP1-SP8 with an orientation and training to the program requirements listed above;

· audit all staff personnel records to ensure the above training has been provided; and

· based on the results of the audit, provide all required trainings to any staff persons that the license holder employs that is not in compliance.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions.

10. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide annual training as required.

The license holder failed to provide SP3 with the following annual trainings:

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04. SP3 completed on May 31, 2024;

· basic first aid. SP3 completed on May 31, 2024.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· provide SP3 with annual training to the program requirements listed above;

· audit all staff personnel records to ensure annual has been provided; and

· based on the results of the audit, provide all required trainings to any staff persons that the license holder employs that is not in compliance.

Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions.

11. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a) and (b).

Violation: For eight staff persons whose records were reviewed (SP1-SP8), the license holder did not maintain documentation in the personnel record as required.

a. The license holder failed to maintain a personnel record for SP1-SP8’s that included the employee’s date of hire.

b. The license holder failed to document the following information in SP1, SP3, SP5-SP7’s personnel record:

· the date the training was completed;

· the number of hours per subject area; and

· the name of the trainer or instructor.

c. The license holder failed to maintain documentation in SP2, SP3, SP4, SP6 and SP7’s personnel record sufficient to determine the date of first unsupervised direct contact with a person served by the program.

d. The license holder failed to maintain documentation in SP3, SP4 and SP7’s personnel record sufficient to determine the date of first supervised contact with a person served by the program.

Corrective Action Ordered: Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Violation: The license holder did not designate a designated coordinator and a designated manager who was responsible for program management and oversight of the services provided by the license holder as required.

a. The license holder failed to designate 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 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; and

• evaluating 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 outcomes has been achieved according to the requirements in section 245D.07.

b. The license holder failed to designate 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; and

· ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met.

Corrective Action Ordered: Within 30 days of receiving this order, you must designate a person or persons that you have identified to perform the duties of the designated coordinator and the designated manager. 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. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions.

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 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

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/