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May 13, 2025 CERTIFIED MAIL Yasin Siyad, Authorized Agent Oakley Care Inc. 6109 Blue Circle Drive Suite 1000 Hopkins, Minnesota 55343 License Number: 1108406 (245D - HCBS) ORDER OF CONDITIONAL LICENSE Dear Yasin Siyad: The Department of Human Services (DHS) is placing Oakley Care Inc.’s license to provide Home and Community-Based Services (HCBS) on conditional status for two years, beginning May 13, 2025. This means you must meet certain conditions to maintain your license, detailed below. This order applies to all services licensed under Chapter 245D and the service sites detailed in the “Applicability of Conditional License” section below. This is based on your noncompliance with Home and Community-Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE Licensing Violations Determined on December 3-4, 2024 and January 13, 2025 DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violation 1. Violation: The license holder did not ensure the designated coordinator and the designated manager (SP5) provided program management and oversight of the services provided by the license holder as required. a. The license holder designated SP5 as the designated coordinator. See citations 2 through 13 regarding the license holder’s failure to ensure SP5 met the following responsibilities: · provide oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · take the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · provide 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 · evaluate the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes have been achieved according to the requirements in section 245D.07. b. The license holder designated SP5 as the designated manager. See citations 2 through 17 regarding the license holder’s failure to ensure SP5 met the following responsibilities: · maintain 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; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; · ensuring corrective action was taken when ordered by the commissioner; and · evaluate the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Service Recipient Violations 2. Violation: For one of nine persons whose records were reviewed (P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP), 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 review the IAPP with P4 and P4’s interdisciplinary team annually in 2023 and 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 3. Violation: For one person whose record was reviewed (P5), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide a written notice that identified the service recipient rights and an explanation of those rights to P5 and P5’s legal representative within five working days of service initiation. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. 4. Violation: For one person whose record was reviewed (P7), the license holder did not meet the requirements for health needs as required. The license holder was assigned responsibility for P7’s health needs, including medication administration. The license holder failed to maintain documentation on how P7’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication administration. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). 5. Violation: For one person whose record was reviewed, (P5), the license holder did not maintain documentation in medication administration record as required. The license holder failed to ensure the following information was documented in P5’s medication administration record: · information on any risks or side effects that were reasonable to expect, and any contraindications to its use; · the possible consequences if the medication or treatment was not taken or administered as directed; · instruction on when and whom to report the following: o if a dose of medication was not administered or treatment was not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment; and · notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by staff or the person or by refusal by the person, or of adverse reaction, and when and to whom the report was made. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). 6. Violation: For one person whose record was reviewed (P9), the license holder did not review medication administration records as required. The license holder failed to ensure that the information maintained in P9’s medication administration record was regularly reviewed to ensure that the information was current and to identify medication administration errors. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 7. Violation: For three persons whose records were reviewed (P5, P7 and P9), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required.
The license holder was assigned responsibility for administering P5’s, P7’s and P9’s psychotropic medications. The license holder failed to maintain documentation that included a description of the target symptoms that each psychotropic medication was to alleviate. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). 8. Violation: For one person whose record was reviewed (P7), the license holder did not provide services in compliance with the requirements of the federal waiver plans. The license holder provided out-of-home crisis respite services to P7. The Community-Based Services Manual (CBSM) stated the following were covered services for crisis respite: · assess the person and situation to determine the factors causing the crisis; and · develop and implement a transition plan to support the person’s return home if they receive out-of-home crisis respite. The license holder failed to provide these covered services. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1. 9. Violation: For two persons whose records were reviewed (P5 and P9), the license holder did not complete service planning for basic support services as required. The license holder failed to review and revise, as needed, P5’s and P9’s preliminary support plan addendum within 60 calendar days of service initiation to document the following: · how, when, and by whom services will be provided; and · the person responsible for overseeing the delivery and coordination of services. The license holder initiated services for P5 on July 10, 2024. The license holder reviewed P5’s preliminary support plan addendum on October 30, 2024. The license holder initiated services for P9 on June 21, 2024. The license holder reviewed and revised P9’s preliminary support plan addendum on September 21, 2024. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 10. Violation: For one person whose record was reviewed (P1), the license holder did not complete service planning for intensive support services as required. The license holder failed to meet with P1, P1’s legal representative, the case manager, other members of the support team or expanded support team, and other people as identified by P1 or P1’s legal representative within 45 calendar days of service initiation. P1 initiated services on July 2, 2024, and the license holder met with P1 and P1’s support team on September 20, 2024. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 11. Violation: For two persons whose records were reviewed (P7 and P9), the license holder did not maintain records as required. The license holder failed to maintain progress or daily log notes recorded by the program in P7’s and P9’s record.
Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 12. Violation: For one person whose record was reviewed (P5), the license holder did not provide written or electronic copies of policies and procedures as required. P5’s services were initiated on July 10, 2024. The license holder failed to inform P5’s case manager and provide copies of the following 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 policy. P5’s case manager received the above-mentioned policies and procedures on November 1, 2024. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. 13. Violation: For one person whose record was reviewed (P4), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate with P4 the identified positive support strategies at least every six months. Statute Violated: Minnesota Rules, part 9555.0030. Repeat Violation: In a Correction Order that DHS issued on May 21, 2024, you were previously found in violation of this same statute. Staffing Standards Violations 14. Violation: For one of four staff persons whose records were reviewed (SP4), the license holder did not maintain staff qualification as required. The license holder failed to ensure staff providing direct support were competent as demonstrated through skills and knowledge training, experience, and education relevant to the primary disability of the person and to meet the person’s needs. The license holder failed to maintain documentation of the provider standards and qualifications for SP4 including demonstrated competency in the orientation and training areas required under this chapter. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 3. 15. Violation: For one staff person whose record was reviewed (SP4), the license holder did not provide orientation training as required. The license holder failed to provide SP4 with an orientation to first aid within 60 days of hire. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. Protection Standard Violation 16. Violation: The license holder did not prohibit the use of mechanical restraint and seclusion as required. The license holder failed to prohibit the use of mechanical restraints and seclusion as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. The license holder developed and maintained positive support transition plans (PSTP) for P7, P8 and P9 that included the targeted interventions of seclusion and mechanical restraint. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 5. Policy and Procedures Violation 17. Violation: The license holder did not establish a program abuse prevention plan (PAPP) as required. The license holder failed to develop a PAPP that assessed the environment for each location where licensed services were provided that included an evaluation of the following factors: · the location of the program in a particular neighborhood or community; and · the type of grounds and terrain surrounding the building. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite ongoing. If you fail to demonstrate substantial compliance with home and community-based services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Nature, chronicity, or severity of violations and effective of violations(s) on health, safety, or rights of persons served by the program The Commissioner considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violations on the health, safety or rights of persons served by the program. Based on this analysis, your license will be placed on a conditional status. · Nature: The license holder was issued a correction order on May 21, 2024, that cited 13 violations. As a result of the correction order, the license holder was provided technical assistance to assist with achieving compliance. Despite the technical assistance provided, and the corrective action that was ordered in the correction order dated May 21, 2024, the license holder continued to demonstrate noncompliance and a failure to provide program coordination, evaluation, and oversight of services at the time of the licensing review on December 3 and 4, 2024, and January 13, 2025. · Chronicity: Your program received its license on April 30, 2021. During the application process you affirmed that you understood licensing rules and laws. DHS provided you direction and resources regarding these rules and laws, including the importance of compliance. Since April 30, 2021, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o May 13, 2025 Conditional License (this order): 17 violations (7 repeat) o March 26, 2025 Correction Order: 2 citations o May 21, 2024 Correction Order: 13 violations · Severity: Many of the violations involve your failure to properly document and review medication administration responsibilities, which could affect the health and safety of the service recipients. You failed to document an individualized description of the procedures to provide medication administration; did not document side effects, reporting procedures, or notation of administration in a medication administration record; or conduct medication reviews to identify and correct medication errors. Failing to ensure service recipients receive the necessary health services and medication could have resulted in significant health implications from those who are dependent on the competent assistance of the license holder. These violations relate to the health and well-being of persons served and put their health at risk. Additionally, you allowed the use of prohibited procedures as a substitute for adequate staffing, for behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. You developed PSTPs for multiple vulnerable adults that allowed for the use of multiple prohibited procedures, including mechanical restraint, manual restraint, and seclusion. Your allowance of prohibited procedures also raises concerns that staff were not adequately trained and did not demonstrate competency on the subjects identified in Minnesota Statutes, section 245D.09, subdivision 4, including 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. This concern is relevant to the staff that developed the PSTPs that allowed for prohibited procedures and the staff that were trained on the implementation of the PSTPs. The designated coordinator and designated manager failed to provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your program remains in compliance with licensing requirements. License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of your failure to hire a qualified and competent designated coordinator and designated manager, you were found in violation of the seventeen citations described in this order. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of: · the program’s operation; · well-being of persons served by your program; · available evaluations of the program by persons receiving services; · information about the qualifications of the direct support staff employed by you; · the ability to demonstrate competent knowledge of applicable laws and rules; and · the results of background studies. DHS is concerned about your program’s operation, well-being of persons served by your program, qualifications of staff, and your ability to demonstrate competent knowledge of applicable laws. DHS is concerned about your program’s operation because since you were licensed in 2021, DHS has issued 3 correction orders and 17 licensing violations determined during the most recent licensing review. The number of violations demonstrates that you failed to adequately oversee your responsibilities as a license holder, to ensure compliance, and take corrective action when ordered by the Commissioner. DHS’ concerns about your program’s operation and ability to demonstrate competent knowledge were also demonstrated in your failure to comply with service planning and health needs documentation requirements. These requirements protect the health and safety of persons served and are minimum standards for license holders. Failure to comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Service planning and health needs requirements are essential to keeping vulnerable adults and children safe and ensuring persons served are receiving necessary services. Your lack of service planning and documentation of health needs posed a risk that staff would not know about the unique needs of the vulnerable people served. Additionally, your allowance of the use of prohibited procedures throughout your program presents concerns about your program’s operation, well-being of persons served, and your ability to demonstrate knowledge of applicable laws. The use of prohibited procedures, including seclusion and mechanical restraints, poses a risk of placing vulnerable adults and children in physical and emotional harm, while also violating their rights. Also, the incorporation of prohibited procedures in service planning documents raises concerns about staff’s qualifications. DHS has determined that an Order of Conditional License is appropriate based on the violations identified above and the program evaluation. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services is placed on a conditional status. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the 17 violations (seven repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. The violations involved your lack of competence to ensure the duties and responsibilities of the designated coordinators and designated managers were met. The lack of oversight led to the allowance of prohibited procedures within persons served support plan addendums. Additionally, you did not ensure the designated manager identified and implemented corrective action ordered by the commissioner in previous actions. The violations also involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, therefore, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, in addition to or other than SP5 who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, in addition to or other than SP5, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the persons who will fulfill the duties and responsibilities of your designated coordinator and designated manager for DHS review and approval. It is your responsibility to ensure that these persons meet the necessary qualifications. You must maintain documentation of your designated coordinator and designated manager’s qualifications in their personnel records and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 30 days of receiving this order, you must submit a written plan to DHS detailing how you will: · ensure the corrective action ordered in this order is completed; and · audit all persons served and staff records for compliance with all applicable rules and statutes. The written plans must detail the roles and responsibilities that your designated coordinator and designated manager will have in completing corrective action and auditing all persons served and staff records. 4. Within 60 days of receiving this order, you must: · complete an audit of all person served and personnel records according to your written plan. The audit must be completed by your designated coordinator and/or designated manager; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · submit the date to your DHS licensor that all person served and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order. 5. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 6. You may not add additional services to this license for the duration of the conditional license. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at kristopher.oberg@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Kristopher Oberg Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Home and Community-Based Services laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community-Based Services are required to follow Minnesota 245A, 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, HCBS Unit Supervisor, at 651-431-6591. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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