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May 16, 2023 Nazneen Hayat Khatoon, Authorized Agent Best Care 3008 University Avenue Southeast Minneapolis, Minnesota 55414 License Number: 1095397 (245D - HCBS) CORRECTION ORDER Dear Nazneen Hayat Khatoon: On May 8, 2023, a licensing review of Best Care, located at 3008 University Avenue Southeast, Minneapolis, 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 (b). Violation: For one of three persons whose record was reviewed (P3), the license holder did not develop the individual abuse prevention plan as required. P3’s service initiation date was March 1, 2022. The license holder failed to develop an individual abuse prevention plan for P3 as part of the initial individual abuse prevention plan, however an individual abuse prevention plan was later developed on June 23, 2022. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For one person whose record was reviewed (P3), the license holder did not provide the person or their legal representative with a written notice that identified the service recipient rights as required. The license holder failed to provide P3 with a notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation, however later provided the rights on May 27, 2022. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for an intensive service as required. a. The license holder failed to complete assessments in the following areas for P1: · P1’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; · P1’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 · P1’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 P1 or others. a. The license holder failed to conduct a 45 day planning meeting for P1. Regarding P1, the license holder failed to meet with the person, the person’s legal representative, if applicable, the case manager and other members of the support team or expanded support team to determine the following based on the information obtained from the assessment: · P1’s identified needs in the support plan, and the requirements regarding service outcomes and reports and person centered planning and delivery: o the scope of the services to be provided to support P1’s daily needs and activities; o P1’s desired outcomes and the supports necessary to accomplish P1’s desired outcomes; o P1’s preferences of how services and supports are provided, including how the provider will support P1 to have control of P1’s schedule; o whether the current service setting is the most integrated setting available and appropriate for P1; o opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; o opportunities for community access, participation, and inclusion in preferred community activities; o opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; o opportunities to seek competitive employment and work at competitively paying jobs in the community; o 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 the continuity of care and coordination of services for the person; o a discussion of how technology might be used to meet the person’s desired outcomes; and o maintain a summary in P1’s coordinated service and support plan addendum of that discussion that included a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · complete the above mentioned assessments for P1; and · review with P1’s support team. On an ongoing basis, you must meet service planning and delivery requirements for an intensive service as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not, within the scope of services, complete assessments as required. The license holder failed to complete assessments for P2 that included information about the person that described the person's overall strengths, functional skills and abilities, and behaviors or symptoms annually in 2022 and 2023. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must complete assessments for P2 that describe the person’s overall strengths, functional skills and abilities, and behaviors or symptoms. On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not meet service plan review and evaluation requirements. The license holder failed to provide reports regarding P2’s progress toward achieving the identified outcomes that: · summarized the person’s progress toward achieving the identified outcomes; · made recommendations; and · identified the rationale for changing, continuing, or discontinuing implementation of supports and methods. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a written plan detailing how you will maintain compliance, on an ongoing basis, as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required. SP2 was hired on January 26, 2022. The license holder failed to provide orientation training in the following areas within 60 days of hire: · data privacy requirements according to 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, however was later provided in August 2022; · 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, however was later provided in August 2022; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3 however was later provided in August 2022; · 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, however was later provided in August 2022; · 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, however was later provided in August 2022; · 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, however was later provided in August 2022; · basic first aid, however was later provided in August 2022; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities, however was later provided in August 2022. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective Action Ordered: On an ongoing basis, you must provide orientation training as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P3), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P3, or their legal representative, and their case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation, however were later provided on June 23, 2022; · grievance policy; · temporary service suspension policy; · service termination policy; · vulnerable adult maltreatment; · emergency use of manual restraints policy; and · data privacy policy. Repeat Violation: The license holder was cited for a similar violation in a correction order dated September 30, 2021. Corrective action ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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 Lindsay Norris at 651-431-5752 as soon as possible. Lindsay Norris, Senior Licensor-Home and Community Based Services Licensing Division Office of Inspector General
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