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May 16, 2025 Ayan Esse Access Health, LLC 2010 East Hennepin Ave Suite 2 Minneapolis, MN 55413 License Number: 1105583 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Ayan Esse: On April 22, 2025, a licensing review of Access Health LLC, located at 2010 East Hennepin Ave, Minneapolis, 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, Minnesota Rules, part 9544.0030, subpart 1. Violation: For one of two persons whose record were reviewed (P1), the license holder did not evaluate positive support strategies as required. P1’s initial positive support strategies were developed in November 2023 and P1 discharged from the program in June 2024. The license holder failed to evaluate identified positive support strategies with P1 at least every six months. Corrective Action Ordered: P1 is no longer receiving services, therefore there is no corrective action ordered. 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 establish written individual abuse prevention plans (IAPP) as required. The license holder failed to include an accurate assessment of P2’s susceptibility to physical abuse. The license holder assessed P2 as not being susceptible to physical abuse in P2’s IAPP. This contradicted information found elsewhere in P2’s record. Corrective Action Ordered: P2 is no longer receiving services, therefore there is no corrective action ordered. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not ensure access to service recipients records as required. The license holder failed to ensure that the staff providing services to P2 had access to the information in P2’s support plan or support plan addendum. Corrective Action Ordered: P2 is no longer receiving services, therefore there is no corrective action ordered. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did not provide orientation to the program as required. The license holder failed to provide SP2 with review of the job description. Corrective Action Ordered: SP2 is no longer employed by the program, therefore there is no corrective action ordered. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, Minnesota Rules, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training 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 annual training to SP1 on the following topics in 2024: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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; · 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: SP1 is no longer employed by the program, therefore there is no corrective action ordered. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one person whose record was reviewed (SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain documentation in SP2’s personnel record that included the name of the trainer or instructor providing the trainings. Corrective Action Ordered: SP2 is no longer employed by the program, therefore there is no corrective action ordered. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245A.66, subdivision 1. Violation: The license holder did establish written policies and procedures related to suspected or alleged maltreatment as required. The license holder failed to identify a secondary person or position to whom internal reports may be made when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. The license holder’s maltreatment of vulnerable adult policy had the same person listed for both the primary and secondary internal contact for whom an internal report may be made. Corrective Action Ordered: Immediately upon receipt of this order, you must update your maltreatment of vulnerable adults policy that meets the statute requirements outlined above. 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 64953 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. Coty Aust, HCBS Licensor Licensing Division Office of Inspector General 651-431-4605
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