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February 20, 2025 Kos Hussein Hassan, Authorized Agent Sumsun Inc. 5701 Shingle Creek Parkway Suite 210C Minneapolis, Minnesota 55430-6604 License Number: 1107876 (245D – HCBS) CORRECTION ORDER Dear Kos Hussein Hassan: On November 22, 2024, a licensing review of Sumsun Inc., located at 5701 Shingle Creek Parkway #210C, Minneapolis, 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 9544.0030 subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not maintain positive support strategies as required. The license holder failed to evaluate the identified positive support strategies with P1 at least every six months and based on the evaluation, determine whether changes were needed in the positive support strategies used. Corrective Action Ordered: 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 record was reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder failed to complete a full individualized assessment of P2’s susceptibility to abuse by other individuals, including other vulnerable adults, P2’s risk of abusing other vulnerable adults, and statements of the specific measures to be taken to minimize the risk of abuse to P2 and other vulnerable adults. The IAPP for P2 did not include an assessment of P2’s susceptibility to sexual abuse, physical abuse, or financial exploitation. b. The license holder failed to identify referrals made when P1 and P2 were vulnerable to abuse outside the scope or control of the licensed services. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a full individualized assessment that identifies P2’s susceptibility to abuse from others, P2’s risk of abusing others, statements of specific measures to be taken to minimize the risk of abuse to P2 in all areas and identify referrals made when P2 is vulnerable to abuse outside the scope or control of the licensed services. The updated IAPP must be provided to P2 and P2’s case manager for review. The documentation of the review by P2 and P2’s case manager must be maintained in P2’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide services as assigned in the support plan as required. The license holder maintained a support plan addendum for P2 dated July 31, 2024. In this support plan addendum, the license holder stated they would provide homemaking services to P2, however, in the service agreement from P2’s case manager, P2 was approved for night supervision services, not homemaking services. The license holder failed to provide services as assigned to P2. Corrective Action Ordered: Immediately upon receiving this order, you must review and update P2’s support plan addendum to include the services approved by P2’s case manager to be provided to P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide person centered service planning as required. a. The license holder failed to provide P1 with person centered service planning and delivery that: · respected P1’s history, dignity, and cultural background; and · provided the most integrated setting and inclusive service delivery. In the support plan addendums for P1 dated September 27, 2023, and April 30, 2024, the license holder stated that the current service setting is not the most integrated setting available and appropriate for P1 with no additional information on what action would be taken to address the service setting. Furthermore, the license holder stated in the support plan addendums related to P1’s history, dignity, and cultural background that “we are a fairly new company and want to gain more experience in the field. Empowering individuals to make decisions about their care and daily activities. We are diverse and welcome diversity”. These statements are not consistent with the history, dignity, and cultural background of P1. b. The license holder failed to provide services to P2 in a manner that supported P2’s preferences, daily needs, and activities and accomplishment of P2’s personal goals and service outcomes, consistent with the principles of person centered planning and delivery that identified and supported what was important to the person as well as what was important for the person, including preferences for when, how, and by whom direct support service is provided. In the support plan addendum dated July 31, 2024, the license holder stated they would provide 56 hours per week of homemaking services to P2. The support plan addendum does not contain any information for P2’s preferences on when, how, or by whom direct support is provided. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P1 to evaluate and update P1’s service plan addendum to include the requirements outlined above. The updated service plan must be provided to P1 and P1’s case manager for review, approval, and signature. The approved service plan must be maintained in the service recipient record as required. · Meet with P2 to evaluate and update P2’s service plan addendum to include the requirements outlined above. The updated service plan must be provided to P2 and P2’s case manager for review, approval, and signature. The approved service plan must be maintained in the service recipient record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete initial service planning as required. a. The license holder failed to review and revise as needed the initial service plan for P1 within 60 calendar days of service initiation. b. The license holder failed to review and revise as needed the initial service plan for P2 within 60 calendar days of service initiation to document the services that will be provided, including how, when, and by whom services will be provided. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), 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 for P1 and P2. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for all persons served. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not make available current policies and procedures as required. a. The license holder failed to inform and provide copies of the policies and procedures affecting P1’s rights to P1’s case manager within five working days of service initiation. P1 initiated services on September 27, 2023, however, P1’s case manager did not receive copies of the required policies and procedures until November 28, 2023.
b. The license holder failed to inform and provide copies of the policies and procedures affecting P2’s rights to P2’s case manager within five working days of service initiation. P2 initiated services on August 1, 2024, however, P2’s case manager did not receive copies of the required policies and procedures until September 3, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For one of two staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. SP2 was hired May 12, 2023. The license holder failed to provide SP2 with the following orientation training: · basic first aid; and · review and instruction on 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 an understanding of the person as a unique individual and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must audit all staff training records to identify staff that have not received all required orientation training. All staff identified in the audit must receive the required orientation training. The documentation of training provided, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor must be maintained in the personnel record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide annual training 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. The license holder failed to provide SP2 with annual training on: · 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; and · basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, you must audit all staff records to identify staff that have not received required annual training on the areas outlined in 245D.09, subdivision 4 and 4a. All staff identified in the audit must receive the required annual training. The documentation of the annual training provided, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor must be maintained in the personnel record as required. 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: For one staff person whose record was reviewed (SP1), the license holder did not meet the requirements for program management and oversight as required. a. The license holder assigned SP1 to the role of designated coordinator. The license holder failed to verify that SP1 met the education and experience qualifications to act in the role of a designated coordinator. The designated coordinator must minimally have: · a baccalaureate degree in a field related to human services, education, or health and one year of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older, or equivalent work experience providing care or education to vulnerable adults or children; · an associate degree in a field related to human services, education, or health and two years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older, or equivalent work experience providing care or education to vulnerable adults or children; · a diploma in a field related to human services, education, or health from an accredited postsecondary institution and three years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older or equivalent work experience providing care or education to vulnerable adults or children; or · a minimum of 50 hours of education and training related to human services and disabilities; and · four years of full-time work experience providing direct care services to persons with disabilities or persons aged 65 and older under the supervision of a staff person who meets the qualifications identified in clauses (1) to (3). b. The license holder assigned SP1 to the role of designated manager. The license holder failed to ensure SP1 minimally met the education and training requirements identified in subdivision 2, paragraph (b), and had a minimum of three years of supervisory level experience in a program that provides care or education to vulnerable adults or children. Corrective Action Ordered: Within 30 days of receiving this order, you must submit to your licensor the education and experience qualifications of SP1 to act in the role of a designated coordinator and designated manager. The documentation of SP1’s education and experience qualifications to act in the role of designated coordinator and designated manager must be maintained in the personnel record as required. 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. 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. Erin White, Home and Community Based Services Licensor Licensing Division Office of Inspector General 651-431-4821
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