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June 27, 2025 Adesola Uchegbu, Authorized Agent Excel Care LLC 4078 Arbor Drive Woodbury, Minnesota 55129 License Number: 1110505 (245D – HCBS) CORRECTION ORDER Dear Adesola Uchegbu: On June 10, 2025, a licensing review of Excel Care LLC, located at 715 Edgerton Street, Saint Paul, 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 2, paragraph a. Violation: For one of four persons whose records were reviewed (P1), the license holder did not establish a program abuse prevention plan (PAPP) as required. The license holder failed to establish a PAPP when the living arrangements were provided by the agency that included: · an assessment of the population including an evaluation of age, gender, mental functioning, physical and emotional health or behavior of the client, the need for specialized programs of care for clients, the need for training of staff to meet identified individual needs, and the knowledge the license holder may have regarding previous abuse that is relevant to minimizing the risk of abuse to clients; · an assessment of the physical plant where the licensed services are provided including an evaluation of the condition and design of the building as it relates to the safety of the clients and the existence of areas in the building which are difficult to supervise; and · an assessment of the environment for each site including an evaluation of the location of program in a particular neighborhood or community, the type of grounds and terrain surrounding the building, the type of internal programming, and the programs staffing patterns. Corrective Action Ordered: Immediately upon receiving this order, you must: · establish a PAPP for each site where you are providing the living arrangements that includes the required criteria outlined above; · post a copy of the completed PAPP in a prominent location in each program that requires the development of a PAPP; · provide an orientation to the PAPP for all service recipients residing at the locations that require a PAPP; and · maintain documentation of this orientation in the service recipient record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not develop and maintain an individual abuse prevention plan (IAPP) as required. a. The license holder failed to develop an IAPP for P1 at service initiation that included a statement of the specific measures that would be taken to minimize the risk of abuse to P1 within the scope of licensed services. Additionally, the license holder failed to include this information in the IAPP for P1 that was reviewed annually in 2024. b. The license holder failed to review P2’s IAPP annually in 2024. c. The license holder failed to develop an IAPP for P3 at service initiation that included a statement of the specific measures that would be taken to minimize the risk of abuse to P3 within the scope of licensed services. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide P2 with a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights annually in 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation related to health service needs as required. The license holder failed to maintain a description in P1’s support plan addendum of the procedures the license holder would follow in order to assist with or coordinate medical, dental and other health service appointments. Corrective Action Ordered: Within 30 days of receiving this order, you must include in the support plan addendum for P1, the procedures you will follow in order to assist with or coordinate medical, dental, and other health service appointments for P1. Once the support plan addendum is updated, you must provide orientation to the staff that work with P1 on these procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not comply with the provision of services as required. According to the Community-Based Services Manual, individualized home supports with family training cannot be provided by a relative. The license holder failed to comply with the federal waiver plan when P3’s relative was hired by the license holder as staff persons to provide P3’s individualized home supports with family training service. Corrective Action Ordered: Immediately, upon receiving this order, you must comply with the provision of services according to the requirements of this chapter and the federal waiver plans. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not meet initial service planning for basic support services as required. The license holder failed to review and revise P2’s preliminary support plan addendum to document the services that would be provided including how, when, and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services within 60 calendar days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s preliminary 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not complete initial intensive service planning as required. The license holder failed to hold an initial planning meeting with P1, P1’s case manager and other members of the support team or expanded support team before providing 45 days of service to determine the following: · the scope of services to be provided to support P1’s daily needs and activities; · P1’s desired outcomes and the supports necessary to accomplish P1’s desired outcomes; · P1’s preferences for how services and supports are provided, including how the provider will support P1 to have control of their own schedule; · whether the current service setting is the most integrated setting available and appropriate for P1; · 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 P1’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 P1 to ensure continuity of care and coordination of services for P1; and · how technology might be used to meet P1’s desired outcomes. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 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 that documented the supports and methods to be implemented to support P1 and accomplish outcomes including: · the methods or actions that would be used to support P1 and to accomplish service outcomes including information about: o any changes or modifications to the physical and social environments necessary when the supports were provided; o any equipment and materials required; and o techniques that were consistent with P1’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: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 3a. Violation: For one person whose record was reviewed (P4), the license holder did not implement their service termination policy as required. The license holder failed to notify P4 and P4’s case manager, in writing, of the intended service termination at least 30 days prior to the termination of services. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not make available policies and procedures as required. The license holder initiated services with P2 on March 8, 2023. The license holder failed to inform and provide copies of the following policies and procedures affecting P2’s rights to P2’s case manager 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. The license holder provided P2’s case manager with these policies on March 22, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide an orientation to abuse prevention plans as required. The license holder failed to provide SP1 and SP2 with an orientation to the license holder’s program abuse prevention plan (PAPP) within 72 hours of first providing direct contact services. Corrective Action Ordered: Immediately upon receiving this order, you must provide SP1 and SP2 with an orientation to your PAPP and you must maintain documentation of SP1 and SP2 receiving this orientation in SP1’s and SP2’s personnel records as required. Within 30 days of receiving this order, you must: · conduct an audit of all staff persons in your program to ensure they received orientation on the program’s PAPP within 72 hours of first providing direct contact services to persons served by the program and annually thereafter; · based on the results of this audit, develop and implement a plan to come into compliance with this subdivision; and · maintain documentation of this audit and plan at your program for review by DHS licensors. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP3), the license holder did not orient staff to individual service recipient needs as required. The license holder failed to provide SP3 with training in the following areas 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 related to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan (IAPP), to achieve an understanding of the person as a unique individual and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP3 with an orientation to the training requirements identified above. Documentation of this training including the date of completion, the number of hours per subject area, and the name of the trainer or instructor must be maintained in the personnel record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one person whose record was reviewed (SP3), the license holder did not provide annual training as required. 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 SP3 with annual training on the following topics in 2025: · 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; · sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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 in; 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: On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain a personnel record as required. The license holder failed to ensure the training documents in SP1-SP3’s personnel records included the hours per subject area. 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 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. Erin White, Home and Community Based Services Licensor Licensing Division Office of Inspector General 651-431-4821
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