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February 27, 2025 Abdulaziz Abukar HagiHussein, Authorized Agent TotalCare Home Health Inc 5701 Shingle Creek Parkway Suite 250K Brooklyn Center, Minnesota 55430-2333 License Number: 1111240 (245D – HCBS) CORRECTION ORDER Dear Abdulaziz Abukar HagiHussein: On December 13, 2024, a licensing review of TotalCare Home Health Inc, located at 5701 Shingle Creek Parkway Suite 250K, Brooklyn Center, 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 (a). Violation: The license holder did not establish and enforce ongoing written program abuse prevention plans (PAPP) as required. The license holder failed to establish and enforce ongoing written abuse program abuse prevention plans. Corrective Action Ordered: Within 30 days of this order, you must: · develop a PAPP including the following: o the assessment of the population shall include an evaluation of the following factors: age, gender, mental functioning, physical and emotional health or behavior of the client; the need for specialized programs of care for clients; the need for training of staff to meet identified individual needs; and the knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; o the assessment of the physical plant where the licensed services are provided shall include an evaluation of the following factors: the condition and design of the building as it relates to the safety of the clients; and the existence of areas in the building which are difficult to supervise; and o the assessment of the environment for each facility and for each site when living arrangements are provided by the agency shall include an evaluation of the following factors: the location of the program in a particular neighborhood or community; the type of grounds and terrain surrounding the building; the type of internal programming; and the program's staffing patterns. · provide orientation to all person served (as applicable) on the PAPP; · provide orientation to all staff on the PAPP; and · maintain record of orientation to the PAPP to the person served and staff. This compliance will be monitored onsite at an upcoming compliance monitoring visit. 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 one of two persons whose records were reviewed (P1), 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. The license holder failed to provide P1 with a notice and explanation of the service recipient rights annually in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with a copy of the service recipient rights and an explanation of those rights. You must also maintain documentation of the receipt of the rights. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. P1’s date of service initiation was October 16, 2023. The license holder failed to review P1’s IAPP at least annually in 2024. b. The license holder failed to include an individualized assessment of the following in P2’s IAPP: · the person’s susceptibility to abuse by other individuals, including other vulnerable adults; · the person’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. c. The license holder failed to include a statement of measures that would be taken to minimize the risk of abuse to P1 and P2 in each person’s IAPP. d. The license holder failed to include measures with specific actions the program would take to minimize the risk of abuse within the scope of licensed services for P1 and P2 in each person’s IAPP. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the IAPPs for P1 and P2 to include the above-mentioned information. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.71, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not complete assessments for intensive service planning as required. Assessments for P2 failed to produce information about the person that described the person’s: · overall strengths; · functional skills and abilities; and · behaviors or symptoms. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise assessments for P2 to include information about the person that describes their overall strengths, functional skills and abilities, and behaviors or symptoms. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d). Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning requirements for intensive services as required. The license holder failed to determine the following during the initial planning meeting held with P2 and P2’s support team: · how services must be coordinated across other providers licensed under Chapter 245D serving the person to ensure continuity of care and coordination of services for the person; and · a discussion of how technology might be used to meet the person’s desired outcomes. Corrective Action Ordered On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraphs (a) and (b). Violation: For one person whose record was reviewed (P2), the license holder did not develop a service plan that documents the service outcomes and supports as required. a. The license holder failed to document the service outcomes and supports within 10 working days of the initial planning meeting. P2’s initial planning meeting occurred on May 27, 2024. The license holder developed P2’s service outcomes and supports on July 12, 2024. b. The license holder failed to include any equipment or materials required to support P2 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision 7. Citation: Minnesota Statutes, section 245D.095, subdivision 2. Violation: The license holder did not maintain an admission and discharge register as required. The license holder failed to maintain an admission and discharge register that listed in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder and deaths. Corrective Action Ordered: Within 30 days of receiving this order, you must establish an admission and discharge register that meets the requirements listed above. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation in the service recipient record as required. The license holder failed to maintain progress notes in P1’s record. Corrective Action Ordered: Immediately, you must begin maintaining progress notes for P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose records were reviewed (SP1), the license holder did not provide and ensure completion of orientation as required. SP1 was hired on September 25, 2024. The license holder failed to provide the following orientation to SP1 within 60 days of hire: · 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; · 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, 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 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 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. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to the individual service recipient needs 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 coordinated service and support plan (CSSP) or coordinated service and support plan addendum (CSSPA); 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 30 days of receiving this order, you must: · complete an audit of all staff records to ensure orientation to service recipient needs for each person they work with has been provided to each staff person; · provide orientation to service recipient needs to any staff persons you identify during the audit as not having been provided each training as required; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required. a. The license holder failed to include documentation of SP1’s completed application and documentation that the employee meets the position requirements as determined by the license holder. b. The license holder failed to include the date the training was completed and the number of hours per subject area in training documentation maintained for SP1 and SP2. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: The license holder did not meet the requirements for program coordination, evaluation and oversight. The license holder failed to ensure that the designated manager (SP3) provided program management and oversight of the services provided by the license holder that include: · 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; · 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 towards accomplishing outcomes identified in section 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, subdivision 4, 4a and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Corrective Action Ordered: Within 30 days of receiving of this order, you must: · develop a comprehensive plan for how you will come into compliance with the requirements 245D, 245A, and the Positive Support Rule, and maintain compliance with the requirements; · ensure all staff persons identified as designated coordinator and/or designated manager for the program understand and have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; · submit the following to your licensor: o the plan you have developed to come into and maintain compliance; and o documentation that the designated coordinators and designated managers have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3. 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 jolene.reinke@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: Jolene Reinke 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. Jolene Reinke, HCBS Licensor Licensing Division Office of Inspector General 651-431-5928
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