|
May 23, 2025 Korme Koji Entrusted Home Healthcare LLC 3141 132nd Avenue NE Blaine, Minnesota 55449 License Number: 1092600 (245D-HCBS) 1115143 (CRS) 1126924 (CRS) CORRECTION ORDER Dear Korme Koji: On April 28 and 29, 2025, a licensing review of Entrusted Home Healthcare LLC: located at 3141 132nd Avenue NE, Blaine, 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 one of two persons whose records were reviewed (P1), the license holder did not provide orientation to the internal and external reporting procedures and Program Abuse Prevention Plan (PAPP) as required. On January 7, 2025, the license holder initiated community residential services (CRS) for P1. The license holder failed to provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults and of the PAPP to P1 and P1’s legal representative within 24 hours of admission as required Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with orientation to the policies and procedures related to suspected or alleged maltreatment and orientation to the PAPP as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, 245A.65, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not establish a written individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1 as part of the initial individual program or service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must develop an IAPP for P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide P1 or P1’s legal representative with the service recipient rights as required. The license holder failed to provide P1 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with a written notice that identifies the service recipient rights and an explanation of those rights as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, 245D.05, subdivision 2, paragraphs (b) and (c). Violation: For two persons whose records were reviewed (P1 and P2), the license holder was assigned responsibility for medication administration in the support plan addendum. The license holder did not implement medication administration procedures as required. The license holder failed to implement medication administration procedures to ensure P1 and P2 take medications and treatments as prescribed. a. the license holder failed to ensure the following information was documented in P1’s MAR: · the information on the current prescription label and the prescriber’s current recorded order that includes the person’s name, description of the medication to be provided, and the frequency and other information needed to safely and correctly administer the medication to ensure effectiveness. b. The license holder failed to make notation in P2’s MAR of any occurrence of a treatment not being performed as prescribed, whether by error by the staff or the person or by refusal by the person. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain a current order for daily and PRN use for P1’s medications that reflects the current quantity of dose, times to administer and what the medication is being used to treat; · ensure correct information of medications is documented on P1’s MAR; and · ensure the administration of ear drops is completed as prescribed and documented appropriately in P2’s MAR. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, 245D.05, subdivision 4. Violation: For two persons who records were reviewed (P1 and P2), the license holder did not review or report on medication and treatment issues as required. The license holder failed to ensure that the information maintained in P1’s and P2’s individual MARs was current. Additionally, the license holder failed to, at a minimum of every three months, review P1’s and P2’s individual MARs to identify medication administration errors. Correction Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, 245D.06, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not obtain authorization of funds and property as required. The license holder is assigned to assist P1 with the safekeeping of funds. The license holder failed to obtain written authorization to do so from the P1’s legal representative and case manager within five working day of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain written authorization from P1’s legal representative and case manager to assist with the safeguarding of funds and property. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: 245D.071, subdivision 3, paragraphs (a-d). Violation: For one person whose record was reviewed (P1), the license holder did not meet requirements for assessments and initial service planning. a. The license holder failed to complete a preliminary support plan addendum based on P1’s support plan within 15 days of service initiation. b. The license holder failed to complete assessments for P1 in the following areas 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 of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. c. The license holder failed to hold an initial planning meeting with the P1, P1’s legal representative, P1’s case manager, other members of the support team or expanded support team, and other people as identified by the P1 or the P1’s legal representative before providing 45 days of service initiation to determine: · the scope of the 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 maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · 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 or expanded support team 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. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must: · create a support plan addendum based off the support plan for P1; · complete the above requirements with P1; and · hold a planning meeting with P1, P1’s legal representative, and P1’s case manager to collectively make determinations on the above-mentioned areas. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop service outcomes and supports as required. The license holder failed to develop a service plan for P1 that documented the service outcome and supports. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete assessments under Minnesota Statutes, 245D.071, subdivision 3; · develop outcomes and supports based off those assessments and include in the support plan addendum; and · document the supports and methods to be implemented to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. The documentation must include: o the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: § any changes or modifications to the physical and social environments necessary when the service supports are provided; § any equipment and materials required; and § techniques that are consistent with the person's communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o 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 o the names of the staff or position responsible for implementing the supports and methods. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not provide copies of policies and procedures as required. The license holder failed to inform and provide copies of the following policies and procedures affecting a persons’ rights to P1 and P1’s case manager within five days of service initiation: o grievance policy; o service suspension policy; o service termination policy; o emergency use of manual restraint policy; and o data privacy. Corrective Action Ordered: Within 30 days of receiving this order, you must provide copies of the above- listed policies to P1, P1’s legal representative, and P1’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, 245D.09, subdivision 5. Violation: For one of three staff persons whose record was reviewed (SP3), the license holder did not ensure annual training was completed 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 SP3 in 2023 on the following topics: · data privacy requirements according to MN Statutes, 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 245D.04; · sections 245A.65, 245A.66, and 626.557 & Ch.260E, governing maltreatment reporting & service planning for children & vulnerable adults, & staff responsibilities related to protecting persons from maltreatment and reporting maltreatment, which includes: o Annual review to VA Maltreatment Reporting; o Annual review of Maltreatment to Minors Reporting; and o Annual review to the LH’s program abuse prevention plan. · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied 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; · basic first aid; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · other topics determined necessary in the person's support plan by the case manager or other areas identified by the license holder. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to ensure the training documents in P1’s personnel record included the name of the trainer or instructor. Corrective Action Ordered: 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. Kathleen “Katie” Crowley HCBS Licensor Licensing Division Office of Inspector General 651-431-2631
|
