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June 30, 2025 Boniface Mwangi Fountain Home Health LLC 11137 Fillmore Street, Northeast Blaine, Minnesota, 55434 License Number: 1112705 CORRECTION ORDER Dear Boniface Mwangi: On May 14, 2025, a licensing review of Fountain Home Health, located at 11137 Fillmore Street 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 2. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not develop an abuse prevention plan as required. The license holder failed to develop an individual abuse prevention plan (IAPP) for P1 and P2 as part of the initial individual program plan or service plan prior to or upon service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must develop IAPPs for P1 and P2 that include: · an individualized assessment of P1’s and P2’s susceptibility to abuse; and · statements of the specific measures that your program will take to minimize those risks of abuse and provide specific support instructions to staff persons implementing P1’s and P2’s plans. Additionally, you must review P1’s and P2’s IAPPs with their case managers and members of their support teams. You must document the review of the IAPP in the person’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statues, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the service recipient rights 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 P1 and P2 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 and P2 with a written notice that identifies the service recipient rights and an explanation of those rights. You must maintain documentation of P1’s and P2’s receipt of a copy and an explanation of the rights in P1’s and P2’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not comply with the requirements of this subdivision. The license holder provided positive supports services to P1. The license holder documented in P1’s support plan addendum the interventions the license holder would implement included “staff training.” The license holder maintained no documentation that indicated the license holder provided training to P1’s staff, formal supports and informal supports. Corrective Action Ordered: Immediately, you must provide services to P1 that comply with the requirement of this chapter and the federal waiver plan. Additionally, you must provide training to P1’s residential staff on the plan developed under this service for P1 and maintain documentation of this training in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2 and 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet service planning requirements for basic support services as required. The license holder failed to complete a preliminary support plan addendum for P1 and P2 within 15 calendar days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a support plan addendum for P2 and document the services that will be provided including how, when and by whom the services will be provided; and · review and revise P1’s and P2’s preliminary support plan addendum to document the services that will be provided including how, when and by whom the services will be provided. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2) the license holder did not inform and provide policies and procedures that affect a person’s rights, as required. The license holder failed to inform and provide copies of the following policies and procedures affecting a person’s rights to P1, P1’s case manager, P2 and 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1, P1’s case manager, P2, and P2’s case manager with the above-mentioned policies and procedures; and · obtain written acknowledgement from P1 and P2 indicating they have been informed of your program’s policy on the emergency use of manual restraint as required in Minnesota Rules, 9544.0090, subpart 1 and maintain the written acknowledgment in the person’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, chapter 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 30 days of receiving this order, you must: · assess P1’s and P2’s strengths, needs, and preferences to identify and create positive support strategies; and · document the positive support strategies for P1 and P2 in an existing plan for the person. Additionally, you must evaluate with the person, at least every six months, the identified positive support strategies and determine whether changes are needed upon the results of the evaluation, and if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation and/or annual training to Vulnerable Adult (VA) maltreatment reporting as required. a. The license holder failed to ensure SP2 and SP3 received orientation to VA maltreatment reporting within 72 hours of first providing direct contact services as required. b. The license holder failed to ensure SP2 received annual training to VA maltreatment reporting in 2024 as required. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide and ensure completion of orientation training as required. The license holder failed to ensure SP2 and SP3 received orientation training on the following topics within 60 calendar days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · consumer grievance and complaint procedures; · consumer temporary service suspension; · consumer service termination; · prohibition on drug and alcohol use policy; · emergency use of manual restraint; · use of universal precautions and sanitary practices; · safe transportation; · service admission; · emergency response, reporting, and reviewing; · incident response, reporting, and reviewing; · data privacy requirements according to Minnesota 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 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 and what constitutes the use of restraints, o time out; o seclusion; o including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5; o why such procedures are not effective for reducing or eliminating symptoms or undesired behavior; and o 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: Within 30 days of receiving this order, you must: · ensure SP2 and SP3 have been orientated and trained on the above-mentioned topics; · audit all staff records to ensure the above orientation has been provided; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (a). Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide SP2 and SP3 with the following training before having unsupervised direct contact with a person served by the program: · 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, 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 SP2 and SP3 orientation and training on all service recipients’ individual needs as stated above. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide annual training as required. The license holder failed to provide SP2 annual training on the following topics in 2024 as required: · data privacy requirements according to Minnesota 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 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 and what constitutes the use of restraints, o time out; o seclusion; o including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5; o why such procedures are not effective for reducing or eliminating symptoms or undesired behavior; and o 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. SP2 was provided these trainings in April of 2023. The license holder provided 2024 annual training on July 16, 2024, September 11, 2024, and September 13, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not maintain personnel records as required. The license holder failed to include the following in SP2’s and SP3’s training record: · documentation of staff qualifications. 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. Kathleen “Katie” Crowley, Human Services Licensor Licensing Division Office of Inspector General 651-431-2631
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