|
July 16, 2025 Raphael Omodunmiju, Authorized Agent Omocare LLC 1506 71st Avenue North Brooklyn Center, Minnesota 55430 License Number: 1116904 (245D – HCBS) 1124728 (CRS) 1124729 (CRS) CORRECTION ORDER Dear Raphael Omodunmiju: On May 28, 2025, a licensing review of Omocare LLC, located at 7708 67th Avenue North, Brooklyn Park 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). Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not establish written policies and procedures and provide orientation related to suspected or alleged maltreatment of vulnerable adults as required. The license holder did not provide P1 and P2 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder initiated P1’s services on July 1, 2024, and provided the orientation on October 1, 2024. The license holder initiated P2’s services on August 1, 2024, and provided the orientation on February 5, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required. The license holder did not orientate P1 and P2 to the program’s PAPP within 24 hours of admission. The license holder initiated P1’s services on July 1, 2024, and provided the orientation to P1 on October 1, 2024. The license holder initiated P2’s services on August 1, 2024, and provided the orientation to P2 on February 5, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must ensure all persons receiving services are provided with an orientation to the PAPP as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder did not develop an IAPP for P1 and P2 as part of the initial individual program or service plan. The license holder initiated P1’s services on July 1, 2024, and developed P1’s IAPP on October 1, 2024. The license holder initiated P2’s services on August 1, 2024, and developed P2’s IAPP on February 1, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide the person with a written notice that identified the service recipient rights as required. The license holder did not provide P1 and P2 with a written notice that identified the service recipient rights within five working days of service initiation. The license holder initiated P1’s services on July 1, 2024, and provided P1 with a written notice that identified the service recipient’s rights on October 1, 2024. The license holder initiated P2’s services on August 1, 2024, and provided P2 with a written notice that identified the service recipient’s rights on February 5, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.04, subdivisions 1 and 3. Violation: For one person whose records were reviewed (P2), the license holder did not ensure the exercise and protection of the person’s protection-related rights as required. P2 resided in a community residential setting (CRS, license number 1124729) where the license holder was the owner, lessor, or tenant. During a walk-though conducted as part of the licensing review, DHS licensors observed vermin droppings in multiple areas within the site. The license holder did not ensure the exercise and protection of P2’s protection-related rights to: · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; and · a setting that is free from hazards that threaten the person's health or safety. Corrective Action Ordered: Immediately upon receipt of this order, you must ensure the exercise and protection of all service recipient rights to each person receiving services under this license. Within 30 days of receiving this order, you must submit a corrective action plan to your licensor that includes the following: · a summary of the measures you have already taken to restore the rights identified above to P2, including the date(s) the measures occurred; · a summary of any additional measures that will take place to restore the rights identified above to P2, including the date(s)those measures will be implemented; and · a detailed plan how your program will maintain compliance on an ongoing basis with ensuring the exercise and protection of the rights mentioned above for all persons who reside in your program’s CRS sites. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not document medication setup as required. The license holder provided medication setup to P1 and P2 as part of medication administration. The license holder did not document the following information for medication setup in P1 and P2’s medication administration records (MARs): · dates of medication setup; · name of the medications; · quantity of dose; · times to be administered; and · route of administration at time of setup. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining documentation of medication setup for P1 and P2 that meets the requirements identified above. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not implement medication administration procedures as required. a. The license holder did not obtain written authorization from P1 and P2 to administer medication or treatment before administering medication or treatment. b. The license holder did not implement medication administration procedures to ensure P1 took medications and treatments as prescribed. The license holder documented in P1’s MAR that P1 missed their medications on multiple instances from December 27, 2024, to May 27, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P1 and P2 to administer medication or treatment; and · begin implementing medication administration procedures to ensure P1’s medications are administered as prescribed. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not document medication administration as required. a. The license holder was responsible for administering P1’s medications beginning July 1, 2024. The license holder did not ensure the following information was documented in P1’s MAR: · the information on the current prescription label or the prescriber's current written or electronically recorded order or prescription that includes the person's name, description of the medication or treatment to be provided, and the frequency and other information needed to safely and correctly administer the medication or treatment to ensure effectiveness; · notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made; and · notation of when a medication or treatment is started, administered, changed, or discontinued. The license holder began maintaining the above mentioned information in P1’s MAR on December 27, 2024. b. The license holder was responsible for administering P1 and P2’s medications. The license holder did not document a notation of when a medication was administered to P1 in over 100 instances from December 27, 2024, to May 28, 2025. The license holder did not document a notation of when a medication was administered to P2 in over 20 instances from December 26, 2024, to May 11, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraphs (a) and (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not ensure medication and treatment issues were reviewed and reported as required. a. The license holder did not conduct a review of P1’s MARs at least every three months to ensure the records were current and to identify medication administration errors. b. The license holder did not conduct a review of P2’s MARs to ensure the records were current and to identify medication administration errors at least every three months between August 1, 2024, and January 31, 2025. Additionally, the license holder did not conduct an accurate review of P2’s MARs for February 2025-April 2025 when the license holder indicated no medication administration errors occurred. P2’s MARs indicated multiple instances during this timeframe where the license holder did not document a notation of whether or not P2’s medications were administered as prescribed. c. P1 refused or missed their medication on multiple dates and the license holder did not report medication errors to P1’s case manager as they occurred. The license holder did not notify P1’s case manager of instances where P1’s medications were not administered as prescribed or P1 refused medications that happened from December 27, 2024, to May 28, 2025. Corrective Action Ordered: Immediately upon receiving this order, you must: · report P1’s medication administration errors to their case manager; and · maintain documentation of the notification regarding medications errors in P1’s record. Within 30 days of receiving this order, you must: · review P1’s and P2’s MARs for the past six months to ensure that the information in the MARs is current and to identify medication errors, including medication administration documentation errors; · based on the review, you must develop, document, and implement a plan to correct patterns of medication administration errors identified; and · maintain documentation of the review and the plan to correct patterns of errors, if applicable, in the person’s MAR. Within 60 days of receiving this order, you must: · review the MARs for the past six months for all other persons your program is assigned the responsibility for medication administration to ensure that the information in the MARs is current and to identify medication errors; · based on the review, you must develop, document, and implement a plan to correct patterns of medication administration errors when identified; and · maintain documentation of the MAR reviews you complete, including the date(s) of completion, and the name of the person(s) who completed the MAR reviews in each person’s record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not meet requirements for psychotropic medication use and monitoring. P1 and P2 were prescribed multiple psychotropic medications. The license holder did not develop and maintain documentation in the person’s support plan addendum that included a description of the target symptoms that each psychotropic medication is used to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must develop and maintain documentation in P1’s and P2’s support plan addendums that includes a description of the target symptoms for each psychotropic medication P1 and P2 are prescribed. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet assessment and initial service planning requirements for intensive support services as required. a. The license holder did not complete a preliminary support plan addendum within 15 calendar days of P1’s and P2’s service initiation. The license holder initiated P1’s services on July 1, 2024, and completed this for P1 on October 15, 2024. The license holder initiated P2’s services on August 1, 2024, and completed this for P2 on February 1, 2025. b. The license holder failed to hold an initial planning meeting with P1, P1’s case manager and other members of P1’s support team, and P2, P2’s case manager, and other members of P2’s support team before providing 45 days of service. The license holder initiated P1’s services on July 1, 2024, and held the initial planning meeting on January 23, 2025. The license holder initiated P2’s services on August 1, 2024, and held the initial planning meeting on February 5, 2025. c. The license holder failed to complete assessments for P1 and P2 before providing 45 days of service that included the person’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being. The license holder initiated P1’s services on July 1, 2024, and completed P1’s assessments on December 15, 2024. The license holder initiated P2’s services on August 1, 2024, and completed P2’s assessments on February 1, 2025. d. The license holder did not hold a discussion of how technology might be used to meet the person’s desired outcomes at P1 and P2’s initial planning meetings. Additionally, the license holder failed to maintain a summary of this conversation in P1 and P2’s support plan addendums that included a statement regarding any decision that was made regarding the use of technology and a description of any further research that needed to be completed before a decision regarding the use of technology could be made. The license holder included this information in P2’s support plan addendum on April 18, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P1, P1’s case manager, and members of the support team to discuss how technology might be used to meet the person’s desired outcomes. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. You must include a summary of this discussion in P1’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop and implement service outcomes and supports as required. a. The license holder did not develop a service plan for P1 and P2 that documented the following supports and methods to be implemented to support the person and accomplish outcomes within ten working days of the initial planning meeting: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · 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 · the names of the staff or position responsible for implementing the supports and methods. The license holder held P2’s initial service planning meeting on February 5, 2025, and developed a service plan for P2 that documented these supports and methods on April 18, 2025. b. The license holder did not implement the supports and methods documented in P2’s service plan. · The license holder documented in P2’s supports and methods that “auditory role-playing scenarios” would be developed. The license holder did not maintain these scenarios in P2’s support plan addendum or at the service site. · The license holder documented in P2’s supports and methods that data would be collected “after each session and charted on a weekly basis”. The license holder failed to maintain data in P2’s support plan addendum or at the service site. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan for P1 that documents the service outcomes and supports and methods listed above and maintain this in P1’s record; · train all staff persons who work with P1 on P1’s outcome and how to implement the outcome. You must maintain documentation that this training was provided in the staff persons’ personnel record; and · review and revise, as needed, P2’s supports and methods and begin implementing the supports and methods; and · train all staff persons who work with P2 on P2’s outcome and how to implement the outcome. You must maintain documentation that this training was provided in the staff person’s personnel record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not maintain service recipient records as required. The license holder did not maintain P2’s current support plan or the portion of the plan assigned to the license holder in P2’s service recipient record. The license holder stated that they received P2’s support plan from P2’s case manager and they did not maintain the support plan they received in P2’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must request a copy of P2’s current support plan or that portion of the support plan assigned to you. Upon receipt of the plan, you must maintain it in P2’s service recipient record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.095, subdivision 2. Violation: The license holder did not maintain an admission and discharge register as required.
The license holder did not keep a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder and deaths. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain an admission and discharge register of all persons served by the program that includes the above-mentioned information. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights under section 245D.04, as required. The license holder did not inform and provide copies of the policies and procedures affecting a person’s rights to P1 and P1’s case manager, and P2 and P2’s case manager within five working days of service initiation. The license holder initiated P1’s services on July 1, 2024, and provided the policies on October 1, 2024. The license holder initiated P2’s services on August 1, 2024, and provided the policies on February 5, 2025. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Rule, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not review positive support strategies as required. The license holder did not evaluate with P1 the identified positive supports strategies at least every six months to determine whether changes needed to be made to the positive support strategies used. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P1 and whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed based upon the results of the evaluation, and if so, make appropriate changes. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subpart.
17. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to internal and external reporting procedures of alleged or suspected maltreatment as required. a. The license holder did not provide orientation training to vulnerable adult maltreatment reporting to SP1 and SP2 within 72 hours of first providing direct contact. b. The license holder did not provide orientation to SP1 and SP2 on the license holder’s program abuse prevention plan within 72 hours of first providing direct contact. The license holder had not provided SP1 training to the license holders program abuse prevention plan at the time of the licensing review. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with orientation to your program abuse prevention plan. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required with this subdivision. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. SP1’s hire date was August 1, 2024. The license holder did not provide the following trainings to SP1 within 60 days of hire: · the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D including their location and access, and staff responsibilities related to the implementation of those policies and procedures; and · 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 license holder provided this to SP1 on October 2, 2024. b. The license holder did not provide the following trainings to SP2 within 60 days of hire. SP2’s hire date was July 12, 2024, and the license holder provided the following trainings to SP2 between September 20, 2024, and October 11, 2024: · a job description and how to complete specific job functions including responding to and reporting of incidents as required under Minnesota Statutes, section 245D.06, subdivision 1, and following safety practices established by the license holder as required in Minnesota Statutes, section 245D.06, subdivision 2; · the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D including their location and access, and staff responsibilities related to the implementation of those policies and procedures; · data privacy requirements according to Minnesota Statutes, section 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 as staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · the principles for person-centered 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 restraints; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or elimination 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 health relationships, consent, and bodily autonomy of people with disabilities. c. The license holder did not provide the following orientation to SP1 and SP2 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 IAPP, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. SP1 had unsupervised direct contact with persons served by the program on August 1, 2024. The license holder did not provide the above mentioned orientation to SP1 until August 18, 2024. SP2 had unsupervised direct contact with persons served by the program on September 12, 2024. DHS Licensors could not determine that the license holder provided SP2 with the above mentioned orientation during the licensing review. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with training on your current policies and procedures under Minnesota Statutes, chapter 245D including their location and access, and staff responsibilities related to the implementation of those policies and procedures. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. a. The license holder did not document the date of SP1 and SP2’s training on medication administration orientation. b. The license holder did not document the number of hours per subject area and name of the instructor for SP1 and SP2’s training on individual needs orientation. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above-mentioned information in SP1 and SP2’s personnel records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required with this subdivision. 20. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a). Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. The license holder’s policy titled “Maltreatment of Vulnerable Adults Mandated Reporting Policy” did not identify the following: · the secondary person or position to whom internal reports may be made; · the secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5; and · the secondary person or position who will ensure that, when required, internal reviews are completed. This section required that the secondary person must be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise your program’s policy related to the suspected or alleged maltreatment of vulnerable to ensure the policy identifies a secondary person or position responsible for requirements identified above; · provide a written notice to all persons or their legal representatives and case managers that explains the revision that was made and include a copy of the revised policy according to the requirements in section 245D.10, subd. 4; · maintain documentation that you provided this written notice, including the date it was provided, in all persons service recipient records; · inform all staff persons of the revisions to this policy and provide training to all staff persons on the implementation of the revised policy according to the requirements in section 245D.10, subd. 4; · maintain documentation that you provided this training to all staff persons in each staff person’s personnel record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain this policy as required in this subdivision. 21. Citation: Minnesota Statutes, section 245A.041, subdivision 4. Violation: The license holder did not ensure electronic records were maintained and stored to allow for review by DHS as required. The license holder did not ensure the use of electronic keeping did not limit the commissioner’s access to records as identified in section 245A.04, subdivision 5. The license holder utilized an electronic record keeping system and was unable to access records during the licensing review. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure electronic records for all persons served are maintained and stored in a manner that allows for review by the commissioner. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 22. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements of program coordination, evaluation and oversight. a. The license holder did not ensure that the staff person the license holder identified as the designated coordinator (SP3) provided supervision, support, and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · 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 · evaluation of the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria has been achieved according to the requirements in section 245D.07. Citations 1 through 21 are evidence of the license holder’s lack of program coordination and oversight of the services. b. The license holder did not ensure that the staff person the license holder identified as the designated manager (SP3), performed the required program management and oversight of the services provided by the license holder that included: · maintaining a 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 (g); · ensuring the duties of 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 care staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) through (6) to develop, document, and implement ongoing program improvements. Citations 1 through 21 are evidence of the license holder’s lack of program management and oversight of the services provided. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the staff person(s) identified as designated coordinator and designated manager for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and · maintain a signed document that the designated coordinator(s) and designated manager(s) have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at nicole.m.riley@state.mn.us or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Nicole Riley Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Nicole Riley, HCBS Licensor Licensing Division Office of Inspector General 651-431-3657
|
