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March 21, 2025 Luqman Ibrahim, Authorized Agent SeCure Care LLC 1509 Southcross Drive West STE 104 Burnsville, Minnesota, 55306 License Number: 1110586 (245D – HCBS) CORRECTION ORDER Dear Luqman Ibrahim: On March 4, 2025, a licensing review of SeCure Care LLC, located at 1509 Southcross Drive West STE 104, Burnsville, 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. Violation: For two of two persons whose records were reviewed (P1 and P2), 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 and P2 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. 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 notify P1’s legal representative of the orientation; · provide an orientation to the internal and external reporting procedures to P2; and · maintain documentation of this orientation as required in section 245D.095, subdivision 3. Compliance with this order will be reviewed 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 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for abuse prevention plans as required. a. The license holder assessed P2 as being vulnerable to physical abuse and self-abuse. The license holder failed to include measures with specific actions the program would take to minimize the risk of abuse within the scope of services in P2’s individual abuse prevention plan (IAPP). b. The license holder failed to review and review P2’s IAPP annually in 2025. Corrective Action Ordered: Within 60 days of receiving this order, you must review and revise P2’s individual abuse prevention plan to include specific measures that would be taken to minimize the risk of abuse in each assessed area of risk of abuse. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statues, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet service recipient rights requirements. a. The license holder initiated P1’s services on July 30, 2024. The license holder failed to provide P1’s legal representative with a written notice that identified the service recipient rights within five working days of service initiation. Additionally, the license holder failed to maintain a receipt of a copy and an explanation of the rights. b. The license holder failed to provide P2 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P2 with a written notice that identifies that service recipient rights and an explanation of those rights. Additionally, you must maintain a copy of the written notice and explanation in P2’s service recipient record. Compliance with this order will be reviewed 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.07, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and 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 county support plan and support plan addendum as required. a. The license holder documented the responsibility of P1’s services and support delivery to P1’s family, whom P1 lived with. The license holder failed to document services and supports that would be provided by the license holder in P1’s support plan addendum. b. The license holder documented the responsibility of services and support delivery to P2’s customized living facility, where P2 lived. The license holder failed to document services and supports that would be provided by the license holder in P2’s support plan addendum. c. P2’s county support plan documented that P2 had erratic behavior, suicidal ideation, and a history of mental health challenges. The license holder documented “N/A” [non-applicable] in a form titled “Coordinated Service and Support (CSSP) Addendum-Intensive Services” that was maintained in P2’s support plan addendum. The license holder failed to document how the license holder would support P2 with their mental health needs within the scope of the services the license holder provided to P2. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and revise P1’s and P2’s support plan addendums to include documentation specifying the services that will be provided to P1 and P2 by the license holder; · provide copies of the updated support plan addendum to P1’s and P2’s expanded support team for review. You must maintain evidence that the support plan addendums were provided to P1’s and P2’s expanded support teams; · provide orientation to P1’s and P2’s direct support staff persons’ on P1’s and P2’s revised support plan addendums and how to implement them. You must maintain document of this training in the staff person’s personnel records; and · maintain copies of the updated support plan addendums in P1’s and P2’s service recipient records. Compliance with this order will be reviewed 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. Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments for intensive service planning as required. The license holder failed to complete assessments for P1 that produced information about P1 that described the person’s overall strengths, functional skills and abilities, and behaviors or symptoms before providing 45 days of service: · 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; · 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 · 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 or services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete the required assessments for P1 that produce information about P1 that describes P1’s overall strengths, functional skills, and abilities; · review the results of the assessments with P1, P1’s case manager and members of the support team; and · maintain documentation of these assessments and the review in P1’s service recipient record. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet initial service planning requirements for an intensive service as required. a. The license holder initiated P1’s service on July 30, 2024. The license holder failed to complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation. The license holder maintained a support plan addendum in P1’s record that was dated September 15, 2024. b. The license holder failed to hold an initial service planning meeting within 45 days of service initiation. The license holder documented that an initial service planning meeting was held on October 30, 2024. Additionally, the license holder failed to include P1’s case manager in P1’s initial service planning meeting. Corrective Action Ordered: Within 60 days of receiving this order, you must hold a service planning meeting with P1, P1’s legal representative, P1’s case manager and members of the support team. You must maintain documentation of the meeting in P1’s service recipient record, including the following: · what was discussed and determined; · who attended the meeting; and · date and time of the meeting. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (a) and (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet service outcome and support development requirements for an intensive service as required. The license holder failed to document the supports and methods to be implemented to support P1 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. This documentation must include: · 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 were provided; o any equipment and materials required; and o techniques that were consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a person-centered service outcome(s) for P1; · maintain the above-mentioned documentation in P1’s service recipient record; and · train all staff persons who work with P1 on the outcome and how to implement the supports and methods. You must maintain documentation of this training in the staff person’s personnel records according to the requirements in 245D.095, subdivision 5. Compliance with this order will be reviewed 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), clause (11). Violation: For six persons whose records were reviewed (P1 through P6), the license holder did not maintain documentation in the service recipient record as required. The license holder failed to maintain daily log notes or progress notes for P1 through P6. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining daily log notes or progress notes in P1’s through P6’s service recipient records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not inform and provide copies of policies and procedures as required. The license holder initiated P1’s services on July 30, 2024. The license holder initiated P2’s services on February 12, 2024. The license holder failed to inform P1 and P2, and P1’s and P2’s case managers 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 policy and procedure; · service termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Corrective Action Ordered: Within 60 days of receiving this order, you must: · inform and provide copies of the above-mentioned policies and procedures to P1, and P1’s and P2’s case managers; and · obtain written acknowledgement from P1’s legal representative that P1 has been notified of your program’s emergency use of manual restraints policy as required in Minnesota Rules, part 9544.0080. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to incorporate in writing positive support strategies to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop positive support strategies for P1 and P2; · document the established positive support strategies in P1’s and P2’s support plan addendum; · provide training on these positive support strategies to P1’s and P2’s direct support staff; · evaluate the established positive support strategies with P1 and P2 a minimum of every six months; and · maintain documentation of this evaluation in P1’s and P2’s service recipient records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, 9544.0110. Violation: For one person whose record was reviewed (P2), the license holder did not report behavioral incidents as required. P2’s case manager reported that 911 was summoned for P2 as a result of a mental health crises occurring on or around September 12, 2024. The license holder failed to report the above incident that involved P2 to the commissioner using the behavior intervention reporting form (BIRF) required by the commissioner. Corrective Action Ordered: Within 15 days of receiving this order, you must: · report the above-mentioned incident using the BIRF form required by the commissioner; and · maintain the BIRF form in P2’s record. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.06, subdivision 1, paragraph (a). Violation: For one person whose record was reviewed (P2), the license holder did not respond to incidents as required. The license holder failed to report incidents to P2’s case manager within 24 hours. Additionally, the license holder failed to follow the program’s “Incident Response, Reporting and Review Policy” when the license holder failed to follow reporting procedures and conduct reviews of the incident involving P2. Corrective Action Ordered: Within 30 days of receiving this order, you must: · report the incidents documented in citation 11 to P2’s case manager; · maintain documentation of this notification in P2’s service recipient record; · complete a written report for the incident documented in citation 11 involving P2. The written report must include: o the name of the person or persons involved in the incident; o the date, time and location of the incident; o a description of the incident; o a description of the response to the incident and whether a person’s support plan addendum or program policies and procedures were implemented as applicable; o the name of the staff person or persons who responded to the incident; · complete a review of the incident involving P2. The review must: o ensure that the written report for the incident provides a written summary of the incident; o identify trends or patterns, if any, and determine if corrective action is needed; and · if it is determined corrective action is needed, take corrective action within the time period specified in your program’s Incident Response, Reporting and Review Policy. You must document any corrective action that must be completed, including the date it was completed. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. The license holder failed to provide SP1 and SP2 with the following trainings within 60 days of hire: · principles of person-centered service planning and delivery 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; · 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 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 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 (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP1 and SP2 with the above-mentioned training; and · maintain documentation of this training in SP1’s and SP2’s personnel records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinator (SP3), 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 · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder failed to ensure that the designated manager (SP3) provided program management and oversight 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 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, subdivision3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a, and 5; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations 1 through 14 for the designated coordinator and designated manager’s failure to provide the above stated requirements. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a staff person, other than SP3, as your designated coordinator who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP3, as your designated manager to provide program management and oversight of the services provided by the license holder; and · submit the name or names and qualifications of the individual(s), other than SP3, who will fulfill these roles to your licensor for review and approval; and · submit a signed acknowledgement that the newly designated person(s) has reviewed and understand the responsibilities of the designated coordinator and designated manager according to 245D.081, subdivision 3, paragraph (a). The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. On an ongoing basis, you must maintain compliance as required in this subdivision. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. 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. Kate Spenger, Human Services Licensor Licensing Division Office of Inspector General 651-431-5757
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