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March 14, 2025 Abdurahman Warsama Jama, Authorized Agent Mercy Link LLC 7400 Metro Boulevard Suite 150 Minneapolis, Minnesota 55439 License Number: 1080519 (245D – HCBS) Investigation Number: 202406542 CORRECTION ORDER Dear Abdurahman Warsama Jama: On January 22, 2025, a licensing review and licensing investigation of Mercy Link LLC, located at 7400 Metro Boulevard, 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 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a), clause 4. Violation: For two of four persons whose records were reviewed (P1 and P3), the license holder did not provide an orientation to the reporting procedures of alleged or suspected maltreatment of vulnerable adults and the program abuse prevention plan (PAPP) as required. a. The license holder failed to provide P1 and P3 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. b. The license holder failed to provide P3 and P4 with orientation to the PAPP within 24 hours of admission. The license holder initiated services for P3 on June 17, 2024; however, the license holder failed to provide P3 the required orientation until July 9, 2024. Corrective Action Ordered: Within 30 days of receiving the order, you must provide orientation to: · P1 and P3 on your internal and external reporting procedures of alleged maltreatment of vulnerable adults; and · P4 on your PAPP. 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 245A.65, subdivision 2. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not establish and enforce individual abuse prevention plans as required. Minnesota statues, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder failed to develop an individual abuse prevention plan (IAPP) for P1, P2, P3, and P4 as part of the initial individual program plan or service plan. · The license holder initiated services for P3 on June 17, 2024; however, the license holder failed to develop an IAPP for P3 until July 3, 2024. · The license holder initiated services for P4 on December 14, 2022; however, the license holder failed to develop an IAPP for P4 until December 20, 2022. b. The license holder failed to review the IAPP for P4 with the interdisciplinary team annually and revise the plan to reflect the results of this review. The license holder reviewed the IAPP with P4’s interdisciplinary team most recently in December 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1 and P2 to include individualized assessments of susceptibility to abuse and provide statements of the specific measures that would be taken to minimize the risk of abuse for each assessed area; and · review P1’s, P2’s, and P4’s IAPP with the person and their case manager. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide service recipient rights as required. a. The license holder failed to provide P1 and P3 a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. The license holder initiated services for P3 on June 17, 2024. The license holder provided P3 with a notice and explanation of the service recipient rights in July 2024. b. The license holder failed to provide P2 and P4 a written notice that identified the service recipient rights and an explanation of those rights annually. · The license holder most recently provided P2 with a notice and explanation of the service recipient rights in September 2023. · The license holder most recently provided P4 with a notice and explanation of the service recipient rights in December 2022. Corrective Action Ordered: Immediately, you must provide all persons and their legal representatives, as applicable, a written notice of the service recipient rights. You must maintain documentation of the person’s or the person’s legal representative’s receipt of the copy and an explanation of the rights according to Minnesota Statutes, section 245D.095, subdivision 3. 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.051, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not develop, implement and maintain documentation regarding psychotropic medications as required.
a. The license holder was assigned responsibility for administration of P3’s psychotropic medications. The license holder failed to develop the following documentation in P3’s support plan addendum: · a description of the target symptoms that the psychotropic medications are to alleviate; and · document methods that will be used to monitor and measure changes in the target symptoms that are to be alleviated by the psychotropic medications. b. The license holder was responsible for collecting and reporting on P3’s psychotropic medication and symptom related data to the prescriber and provide the monitoring data to the expanded support team for review quarterly in 2024. The license holder failed to report on the psychotropic symptom related and monitoring data to the prescriber and the support team. "Target symptom" refers to any perceptible diagnostic criteria for a person's diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain documentation in P3’s support plan addendum that includes the description of the target symptoms that each psychotropic medication was to alleviate; and · report on the psychotropic symptom related and monitoring data to P3’s prescriber and support team. 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.06, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not meet the requirements for safeguarding and handling a person’s funds. The license holder was responsible for the safekeeping of funds for P3. The license holder failed to survey, document and implement the preferences of P3’s legal representative and P3’s case manager for frequency of receiving a statement that itemizes receipts and disbursement of funds. Corrective Action Ordered: Within 30 days of receiving this order, you must survey, document and implement the preferences of P3’s legal representative and P3’s case manager for frequency of receiving statements and disbursement of funds. 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.07, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete service planning as required. a. The license holder failed to: · develop a preliminary support plan addendum for P1 within 15 calendar days of service initiation; and · review and revise P1’s preliminary support plan addendum within 60 days of service initiation to document the services that would be provided including, how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. b. The license holder provided multiple services to P2. The license holder failed to ensure that P2’s support plan addendum identified how services were provided for each service, including how, when and by whom. Corrective Action Required: Within 30 days of receiving this order, you must: · develop P1’s support plan addendum to document the services that will be provided including, how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services; and · review and update P2’s support plan addendum to include how each service will be provided, including how, when, and by whom. 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 Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d). Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not complete service planning as required. P3’s service initiation was on June 17, 2024. P4’s service initiation was on December 14, 2022. The license holder failed to meet with P3, P3’s legal representative, P3’s case manager, P4 and P4’s case manager within 45 days of service initiation to determine the following: · the scope of services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; · the person’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; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; · opportunities for community access, participation and inclusion in preferred community activities; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team to ensure continuity of care and coordination of services for the person; · a discussion of how technology might be used to meet the person’s desired outcomes; · summarize this conversation and include it in the person’s support plan addendum; and · include a statement in the summary 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. The license holder met with P3 and their team on August 5, 2024 and determined the information detailed above. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P4 and P4’s case manager to determine the requirements listed above and revise P4’s support plan addendum to include the information listed above. 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 Statutes, section 245D.071, subdivision 4, paragraphs (a) and (b). Violation: For two persons whose record were reviewed (P3 and P4), the license holder did not document service outcomes and supports as required. The license holder failed to document in P3’s and P4’s support plan addendums the following supports and methods to be implemented to support P3 and P4 and accomplish outcomes: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; 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 and document the information listed above in P3’s and P4’s support plan addendums. Additionally, you must summarize the person’s status and progress toward achieving the identified outcomes at the time of progress review meetings. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose record were reviewed (P1 and P3), the license holder did not maintain service recipient record as required. The license holder failed to maintain progress or daily log notes for P1 and P3 that were recorded by the program. Corrective Action Ordered: Immediately, you must begin maintaining progress or daily log notes for P1 and P3. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not inform and provide written or electronic copies of policies and procedures as required. a. The license holder failed to inform and provide copies to P1 and P1’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 and procedure; · service suspension and termination policy and procedure; and · emergency use of manual restraints policy and procedure. b. The license holder failed to inform and provide copies to 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 and procedure; and · service suspension and termination policy and procedure. c. The license holder failed to inform and provide copies to P3and P3’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 and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. P3’s service initiation was June 16, 2024. The license holder provided P3 and P3’s case manager the required policies and procedures on July 3, 2024. d. The license holder failed to inform and provide copies to P4’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 and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Corrective Action Ordered: Immediately, you must inform and provide copies of the above mentioned policies and procedures to P1, P1’s case manager, P2’s case manager and P4’s case manager. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, chapter 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not incorporate and evaluate positive support strategies as required. a. The license holder failed to incorporate positive support strategies for P1 and P2 and implement the positive support strategies in writing into an existing support plan. b. The license holder failed to evaluate the identified positive support strategies with P4 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and implement positive support strategies in writing for P1 and P2; · evaluate the identified positive support strategies with P1, P2 and P4; and · review the positive support strategies with P1, P2 and P4 every six months. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 12. Citation: Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide notice 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 P1 indicating that P1 had been notified of the license holder’s emergency use of manual restraints policy. Corrective Action Ordered: Immediately, you must obtain a written acknowledgement from P1 that P1 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. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of four staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to mandated reporters as required. The license holder failed to provide SP1 and SP2 orientation to the license holder’s PAPP within 72 hours of first providing direct contact services. Corrective Action Ordered: Immediately, you must provide SP1 and SP2 orientation on the facility’s PAPP. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not meet the requirements for program management and oversight. a. The license holder identified SP4 as the designated manager; however, the license holder failed to ensure SP4 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 provided care or education to vulnerable adults or children. b. The license holder failed to ensure that the designated manager (SP4) provided program management and oversight of the services provided. See citations 1 through 9 for the designated manager’s failure to: · maintain 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 (b); · ensure 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 sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; and · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person other than SP4 to perform the duties of the designated manager that meets the qualifications according to Minnesota Statutes, section 245D.081, subdivision 3; and · verify and document their qualifications according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivision 3. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required.
The license holder failed to provide SP1 and SP2 with orientation in the following areas: · the job description and how to complete specific job functions, including, following safety practices established by the license holder as required in section 245D.06, subdivision 2; · the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location, access, and staff responsibilities related to implementation of those policies, including: o consumer grievance and complaint procedures; o consumer temporary service suspension; o consumer service termination; o prohibition of drug and alcohol use policy; o emergency use of manual restraint; o use of universal precautions and sanitary practices; o health service coordination and care; o safe transportation; o service admission; and o emergency response, reporting, and review; and · basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 and SP2 with the trainings listed above; and · maintain documentation of these training as required in section 245D.095, subdivision 5. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. 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 individual service recipient needs as required.
The license holder failed to provide SP1 and SP2 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 ensure SP1 and SP2 have reviewed and received instructions on each individual service recipient they are providing direct support service to. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. 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 personnel records as required.
The license holder failed to maintain personnel records for SP1 and SP2 that documented the following: · date of first supervised direct contact with a person served by the program; and · date first unsupervised direct contact with a person served by the program. Corrective Action Ordered: Immediately, upon receiving this order, you must maintain personnel records for all employees that document the above-mentioned requirements. Compliance with this corrective action will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245C.07, paragraph (f). Violation: For eleven staff persons whose records were reviewed (SP2, SP4-SP13), the license holder did not affiliate staff persons to all rosters the persons were working under as required. The license holder failed to affiliate SP2, and SP4-SP13 to all required rosters under license number 1110637. A background study was submitted under license number 98108, however, SP2, and SP4-SP13 were also working under license number 1110637. Corrective Action Ordered: Immediately, you must affiliate SP2 and SP4-SP13 to your roster under license number 1110637. Compliance with this corrective action will be reviewed onsite. 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. Tammi Mitei, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6341
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