|
January 9, 2025 RE: Mercy Link, LLC License Number: 1080519 (245D HCBS)
Abdurahman Jama, Authorized Agent Mercy Link LLC 7400 Metro Boulevard Suite 150 Edina, Minnesota 55439 Dear Abdurahman Jama: This matter arises from an Order of Conditional License (“the Order”) that the Minnesota Department of Human Services (DHS), Licensing Division, issued to Mercy Link, LLC. (“Mercy Link” or “you”) dated August 28, 2025 (See attached Exhibit A). On September 11, 2025, DHS received your request for reconsideration. DHS’ response to the violations and conditional order are addressed below. A. RECONSIDERATION OF THE CITATIONS IN THE ORDER OF CONDITIONAL LICENSE In your request for reconsideration, you state you are challenging all eighteen violations; however, you did not contest them and for most you acknowledge you did not comply with the law. Since you did not contest the 18 violations, they are affirmed. However, you provided information for DHS to consider about violations 1, 2 and 3, which will be addressed below: Violation 1: This citation was issued because the Designated Coordinator and Designated Manager did not meet the requirements for program management and oversight, in violation of Minnesota Statutes, section 245D.081, subdivision 2 and 3. In your request for reconsideration you state that at the time of the licensing review Mercy Link agreed that a new person would serve as the Designated Manager. In your reconsideration request you stated that two days after the licensing review you entered into a consulting agreement with the person. DHS Response: There were eighteen violations identified at the licensing review. You did not ensure the Designated Coordinator and Designated Manager in place at that time met their responsibilities under section 245D.081, as demonstrated by the 18 violations. Citation 1 is affirmed. Violation 2: This citation was issued because you did not provide P3’s legal representative and case manager with an orientation to the internal and external reporting procedures and to the program abuse plan within 24 hours of admission as required by Minnesota Statutes, Section 245A.65, subdivision 1. On reconsideration you state the citation reflects transition period challenges and that you have engaged in professional compliance consulting that included a systematic correction of orientation procedures. DHS response: You did not contest this violation occurred. Although you state you invested in a professional to help you with compliance, you did not comply with this statutory requirement at the time of the licensing review. Citation 2 is affirmed. Violation 3: This citation was issued because the individual abuse and prevention plan (“IAPP”) for three persons whose records were reviewed, P1, P3, and P4 were not in compliance with Minnesota Statutes, Section 245A.65, subdivision 2. P1 and P3s IAPP stated they were not susceptible to abuse by other vulnerable adults and the IAPP did not include an accurate and individualized assessment of their susceptibility to abuse. For P3 the IAPP did not include specific measures to minimize the risk of abuse. On reconsideration you state the violation was considered a repeat violation without acknowledging remediation efforts. You state that during the exit interview the IAPPs were not described as incomplete but as needing additional details. You state that at the licensing review you acknowledged the licensors input and understood it as a learning opportunity. You state the violation misrepresented the nature of the feedback given to you at the licensing review. DHS response: In your request for reconsideration you did not argue the IAPPs were in compliance, only that you thought that DHS should give you another chance to correct the violation. Because there was a violation, DHS was not in error in issuing the citation. This citation is affirmed. B. RECONSIDERATION OF CONDITIONAL LICENSE Nature, chronicity, severity, and effect on health, safety, and rights The Commissioner considered the nature, chronicity, and severity of the licensing violations and the effect of the violations on the health, safety, or rights of persons served by the program, as required by Minnesota Statutes, section 245A.06, subdivision 1, and has determined that a conditional license is warranted. Regarding the nature of the citations, they involved your inability to understand applicable laws and rules, the failure to document the services you were to provide, and to train staff persons. You state the violations were not serious because DHS did not assess a fine, the issues were related to documents and not the health and safety of clients, that there were no service delivery concerns, and that you engaged in systematic remediation demonstrating a genuine commitment to compliance. However, the nature of the violations directly relate to the health and safety of the persons served. You did not conduct an initial planning meeting for P4 in which you would have discussed P4’s needs and vulnerabilities with their care team. As a result, you did not have the knowledge and documentation from this meeting for P4’s support plan and to train staff. You also did not develop Individual Abuse Prevention Plans, which is an individualized assessment of the person’s risk of abuse and the specific measures that will be taken to keep them safe. You put persons served at risk of neglect and abuse when you did not train staff on maltreatment. Regarding chronicity, in addition to the Conditional License, DHS issued two correction orders and one Order to Pay a Fine to you since April 14, 2019. The Conditional License contained 18 violations, 11 of which were repeat violations from the March 14, 2025, Correction order, showing you did not take corrective measures. Considering these factors, the conditional license is warranted. Commissioner’s Evaluation In determining whether a conditional license is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the program’s operation, the well-being of persons served, available evaluations of the program by persons receiving services, information about the qualifications of staff persons that are working in your program, and the license holder’s ability to demonstrate competent knowledge of the applicable requirements of statutes and rules. DHS determined that it was appropriate to place your license on conditional status based on the violations identified above and the program evaluation. The effect of the violations on the well-being of person’s served is addressed above. Regarding the program’s operation and the demonstration of competent knowledge of statutes and rules, DHS issued a correction order and Conditional License to you within 6 months, with eighteen violations each. In addition, eleven violations cited in the Conditional Order were repeat violations. Regarding staff qualifications, you did not hire a qualified and competent Designated Coordinator and Designated Manager, as demonstrated by the eighteen citations described in the Conditional Order. Based on this recent history of significant noncompliance and on the number and serious nature of the violations in the conditional order, and that you demonstrated a lack of understanding of the law, the Commissioner believes the program can benefit from additional oversight to ensure it can gain and continue compliance with licensing regulations. C. CONDITIONAL LICENSE TERMS The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a managerial staff person, other than SP4, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the person(s) who will fulfill the duties and responsibilities of your designated manager for DHS review and approval. It is your responsibility to ensure that your designated manager meets the necessary qualifications. You must maintain documentation of your designated manager’s qualifications in their personnel record and maintain a signed job description in their personnel record. Changes to these positions may not be made without prior notification and approval by DHS. 3. Within 30 days of receiving this order, you must: · submit a written plan to DHS detailing how you will ensure the corrective action ordered in this order is completed; · submit a written plan to DHS detailing how you will audit all persons served and staff records for compliance with all applicable rules and statutes; and · submit documentation that your program’s designated coordinator and designated manager have reviewed their roles and responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3. 4. Within 60 days of receiving this order, you must: · complete an audit of all participant and personnel records according to your written plan. The audit must be completed by your designated coordinator and/or designated manager; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · submit the date to your DHS licensor that all person served and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order. 5. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 6. You may not add additional services to your HCBS license without prior approval from DHS for the duration of the conditional license. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. D. RIGHT TO APPEAL TO THE MINNESOTA COURT OF APPEALS This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, please contact Brittany Raddatz, Supervisor, at 651-431-6591. Sincerely,
Kofi Montzka, Attorney Legal Counsel’s Office Office of Inspector General
|
