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February 27, 2025 Asad Ahmed Hassan, Authorized Agent Loyal Home HealthCare LLC 4001 Stinson Boulevard Northeast Suite 304 Minneapolis, Minnesota 55421-3434 License Number: 1105224 (245D – HCBS) Complaint Numbers: 202410218; 202407255; and 202406391 CORRECTION ORDER Dear Asad Ahmed Hassan: On December 16, 2024, a licensing review and licensing investigation of Loyal Home HealthCare LLC, located at 4001 Stinson Boulevard Northeast Suite 304, 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 and licensing investigation, 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 1. Violation: For three of five persons whose records were reviewed (P1, P2, and P5), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder failed to provide P1, P2, and P5 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. P2 is no longer receiving services from the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must provide an orientation to the internal and external reporting procedures to P1 and P5. In addition, you must maintain documentation of this orientation as required in section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2 and P5), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. Regarding P1 and P2, the license holder failed to include an individualized assessment of P1 and P2’s susceptibility of abuse according to Minnesota Statutes, section 626.577, subdivision 14; P1 and P2’s IAPPs indicated that P1 and P2 were not susceptible to abuse, however, this assessment was not consistent with information reviewed elsewhere in P1 and P2’s record. b. Regarding P2, the license holder failed to provide an orientation to the program abuse prevention plan (PAPP) within 24 hours of admission. c. The license holder failed to develop an IAPP for P5 as part of the initial individual program plan or service plan. P5’s services were initiated on October 1, 2024, however the license holder failed to develop an IAPP for P5 until November 6, 2024. Additionally, the license holder failed to include an individualized assessment of P5’s susceptibility of abuse according to Minnesota Statutes section 626.557, subdivisions 14; P5’s IAPP indicated that P5 was not susceptible to abuse, however this assessment was not consistent with information reviewed elsewhere in P5’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1 and P5’s IAPPs to meet the requirements of this subdivision; · audit IAPPs for all persons served by your program; and · based on the results, submit a detailed plan describing how you will come into compliance with these requirements and maintain compliance thereafter. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For four persons whose records were reviewed (P1, P2, P4, and P5), the license holder did not provide a written notice that identified 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. Regarding P1, P2, P4, and P5, the license holder failed to maintain documentation of each person’s receipt of a copy and an explanation of the rights within 5 working days of service initiation. Additionally, the license holder failed to provide these rights to P1 and P5 annually. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P4, and P5 with a copy of the service recipient rights and explanation of those rights and maintain documentation of the receipt of rights. On an ongoing basis, you must maintain compliance as required. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P2), the license holder did not provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and support plan addendum as required. Regarding P2, the license holder maintained information in P2’s record that documented P2 desired an outcome related to medical appointments. The license holder failed to develop an outcome related to medical appointments. The license holder failed to provide services in a manner that supported P2’s preferences for service outcomes, consistent with the principles of person-centered planning and delivery. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for basic support services as required. a. P1’s services were initiated on June 9, 2022. The license holder failed to review and revise the preliminary support plan addendum within 60 calendar days of service initiation to document the services that will be provided including how, when and by whom, and the person responsible for overseeing the delivery and coordination of services. b. P1’s support plan addendum required annual service planning and support team meetings and semi-annual written reports regarding P1’s progress or status; however, the license holder failed to meet with the support team or provide written reports based on the established timelines in P1’s support plan addendum. Corrective Action Ordered: Within 30 days, you must: · review and revise P1’s support plan addendum to include the above mentioned information; · meet with P1 and members of P1’s team for a service planning and support team meeting; and · provide P1 and members of P1’s team written reports regarding P1’s progress or status. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P2 and P5), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services. a. Regarding P2, whose services were initiated on March 22, 2024, the license holder failed to: · complete assessments for P2 in the following areas before the initial service planning meeting: o the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; o the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and o the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. · meet with P2, P2’s case manager, and other members of the support team or expanded support team within 45 days of service initiation to determine P2's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; and · a discussion of how technology might be used to meet P2's desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include: · a statement regarding any decision that is made regarding the use of technology; and · a description of any further research that needs to be completed before a decision regarding the use of technology can be made. b. Regarding P5, whose services were initiated on October 1, 2023, the license holder failed to: · at a minimum, complete assessments, within the scope of services, in the following areas before the 45-day planning meeting: o assessments produced information about the person that described P5’s overall strengths, functional skills, and behaviors and symptoms. · meet, within 45 days of service initiation with P5’s case manager, and other members of the support team or expanded support team to determine the following based on information obtained from the assessments identified in paragraph (b), P5's identified needs in the CSSP, and the requirements in subdivision 4 and section 245D.07, subdivision 1a: o P5’s desired outcomes and the supports necessary to accomplish P5’s desired outcomes; o P5’s preferences for how services and supports are provided; § A discussion of how technology might be used to meet the person's desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include: § a statement regarding any decision that is made regarding the use of technology; and § a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Additionally, the license holder failed to conduct assessments annually in 2024 for P5. Corrective Action Ordered: Within 30 days of receiving this order, you must complete assessments of P5 in the areas listed above. In addition, within 30 days of receiving this order, you must meet with P5, their case manager, and other members of the support team or expanded support team to determine the information listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P5), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required. Regarding P2 and P5, the license holder failed to document the following areas in P2 and P5’s current supports and methods for current outcomes: · the measurable and observable criteria for identifying when the desired outcomes has been achieved and how data would be collected; · the projected starting date for implementing the supports and methods; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan that documents the service outcomes and supports listed above for P5; and · train all staff persons who work with P5 on how to implement the service outcomes and supports for the person. You must maintain documentation of this training in staff persons’ personnel records according to the requirements in 245D.095, subd. 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not maintain a service recipient record as required. a. The license holder failed to maintain an admission form signed by P2 that included service information, including service initiation information, verification of the person's eligibility for services, 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. b. The license holder failed to maintain progress notes that are recorded by the program for P2’s outcome data tracking. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not ensure access to the person’s record as required. Regarding licensing investigation report number 202406391, the license holder failed to ensure the case manager had access to the information in subdivision 1 in accordance with applicable start and federal laws, regulations, or rules. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2 and P5), the license holder did not inform the person and case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation as required. a. The license holder failed to provide policies and procedures affecting a person’s rights under section 245D.04 to P1 and P5’s case managers within five working days of service initiation. b. The license holder failed to provide policies and procedures affecting a person’s rights under section 245D.04 to P2 and P2’s case manager within five working days of service initiation. P2 is no longer receiving services from the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must inform P1 and P5’s case managers of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2 and P5), the license holder did not meet the requirements for positive support strategies and person centered planning as required. a. The license holder failed to evaluate with P1 and P5 whether the identified positive support strategies currently meet the standards in subpart 2 at least every six months. b. The license holder failed to incorporate positive support strategies in writing to P2’s existing treatment, service, or other individual plan. P2 is no longer receiving services from the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate with P1 and P5 whether the positive support strategies currently meet the standards in subpart 2. · Based on 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. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three of five staff persons whose records were reviewed (SP2, SP4, and SP5), the license holder did not provide orientation training as required. a. SP2 was hired on May 29, 2024. The license holder failed to provide SP2 with the following trainings within 60 days of hire: · 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. The license holder provided this training to SP2 on December 9, 2024. b. SP4 was hired on September 7, 2022. The license holder failed to provide SP4 with the following trainings within 60 days of hire: · data privacy requirements according to MN Statutes, 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 license holder provided this training to SP4 on November 30, 2022; · 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 license holder provided this training to SP4 on November 30, 2022; · sections 245A.65, 245A.66 & 626.557 & chapter 260E governing maltreatment reporting & service planning for children and vulnerable adults, & staff responsibilities related to protecting persons from maltreatment & reporting maltreatment. The license holder provided this training to SP4 on November 30, 2022; · 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 license holder provided this training to SP4 on November 30, 2022; · 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. The license holder provided this training to SP4 on November 30, 2022; · 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. The license holder provided this training to SP4 on November 30, 2022; · 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. SP5 was hired on November 1, 2023. The license holder failed to provide SP5 with the following trainings within 60 days of hire: · 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. The license holder provided this training to SP5 on March 13, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with training on basic first aid. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff whose records were reviewed (SP4 and SP5), the license holder did not provide annual training as required. a. The license holder failed to provide SP4 with the following annual trainings in 2023 and 2024: · 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; · sections 245A.65, 245A.66, 626.556, and 626.557, 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 and annually thereafter 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; · 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; · 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 SP5 with annual training in 2024 to the license holder’s program abuse prevention plan and basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP4 and SP5 with the above mentioned trainings; · audit the most recent annual training records for all staff to ensure all staff have received annual training on the required topics; and · based on the results of the audit, you must provide annual training to all staff who have not received training on any of the required training topics. 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 lacey.l.walsvik@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: Lacey Walsvik 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. Lacey Walsvik, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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