Minnesota

April 23, 2025 CERTIFIED MAIL

Akinbowale John Barbington, Authorized Agent

New Hope Living & Nursing Services

6901 78 Avenue North Suite 101

Brooklyn Park, Minnesota 55445-2720

License Numbers: 1070370 (Home and Community – Based Services)

1070371 (Community Residential Setting)

1070372 (Community Residential Setting)

1091447 (Community Residential Setting)

1096141 (Community Residential Setting)

1096142 (Community Residential Setting)

1097389 (Community Residential Setting)

1110149 (Community Residential Setting)

1122142 (Community Residential Setting)

1122805 (Community Residential Setting)

1123737 (Community Residential Setting)

1127417 (Community Residential Setting)

ORDER OF CONDITIONAL LICENSE

Dear Akinbowale John Barbington:

The Department of Human Services (DHS) is placing your license to provide Home and Community – Based Services at New Hope Living & Nursing Services on conditional status for two years, beginning April 23, 2025. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Home and Community Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

Licensing Violations Determined on February 4-6, 2025

DHS determined that your program failed to follow licensing rules and statutes, as described below.

Program Coordination, Evaluation, and Oversight Violation

1. Violation: The license holder did not ensure the program management, evaluation, and oversight of the services provided by the license holder as required.

a. The license holder failed to ensure that the designated coordinators (SP1, and SP9-SP15) provided coordination of service delivery and evaluation for each person served by the program. See citations 2 through 28 regarding the designated coordinators’ failure to provide supervision, support and evaluation of the activities including:

· oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service 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 coordinated service and 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 for identifying when the desired outcome has been achieved according to the requirements in section 245D.07.

b. The license holder failed to ensure the designated managers (SP2 and SP8) provided program management and oversight of the services provided to P1-P5 by the license holder. See citations 2 through 28 regarding the designated managers’ failure to:

· maintain 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 (b);

· ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2;

· evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04;

· ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5;

· ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

Statute Violated: Minnesota Statutes, section 245D.081, subdivision 3.

Person Served Violations

2. Violation: For four of five persons whose records were reviewed (P1, P2, P4, and P5), the license holder did not ensure that persons served personal funds were not used by the program to purchase items for which the facility is already receiving public or private payments as required.

The license holder maintained a document titled “Residency/Lease Agreement” for P1, P2, P4, and P5. This document contained rules that stated the person would be responsible to cover the costs of any intentional damages, outside of normal wear and tear, to the community residential setting (CRS) where the person resided. The license holder failed to ensure P1’s, P2’s, P4’s and P5’s personal funds were not used by the program to purchase items for which the facility is already receiving public payments when the license holder implemented the “Residency/Lease Agreement” document.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13.

3. Violation: For three persons whose records were reviewed (P2-P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) 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

a. The license holder assessed P2 as susceptible to sexual abuse in P2’s IAPP dated March 27, 2024. The license holder failed to identify specific measures the program would take to minimize the risk of abuse within the scope of licensed services.

b. The license holder assessed P4 as susceptible to self-abuse in P4’s IAPP. The license holder failed to identify specific measures the program would take to minimize the risk of abuse withing the scope of licensed services. Additionally, the license holder failed to review P4’s IAPP annually in 2024. The license holder reviewed P4’s IAPP on April 6, 2023, and May 29, 2024.

c. The license holder failed to develop an IAPP as part of the initial program plan or service plan prior to or upon service initiation for P3. P3’s services were initiated on May 18, 2024. The license holder failed to develop an IAPP until May 20, 2024.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

4. Violation: For one person whose record was reviewed (P4), 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 provided P4’s legal representative with a notice of the service recipient rights on April 6, 2023, and May 29, 2024. The license holder failed to provide P4’s legal representatives with a notice and explanation of the service recipient rights annually in 2024.

Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1).

5. Violation: For four persons whose records were reviewed (P1, P2, P4, and P5), the license holder did not ensure the exercise and protection of the person’s rights in the services provided as required.

a. P1 lived in a community residential setting (CRS, license number 1070371) operated by the license holder. The license holder failed to ensure the following protection related rights for P1:

· receive services in a clean and safe environment when the license holder is the owner, lessor or tenant of the service site;

· access to personal possessions at any time, including financial resources; and

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin and insects.

b. The license holder failed to ensure the exercise and protection of P4’s right to have access to their personal possessions at any time. P4 did not have access to their clothing. The license holder maintained P4’s clothing in a locked area and only staff was able to access P4’s clothing. Additionally, the license holder limited the amount of time P4 could use their personal iPad and removed their iPad two hours before P4 went to bed. Once the iPad was removed the license holder did not allow P4 to access their iPad for the rest of the day.

c. The license holder maintained a document titled “Residency/Lease Agreement” for P1, P2, P4, and P5. This document contained rules and guidelines that restricted individual rights for the persons service in the facility. Through the implementation of this agreement the license holder failed to ensure the exercise and protection of the P1’s, P2’s, P4’s, and P5’s right to have visitors and choose the time of visits.

Statute Violated: Minnesota Statutes, section 245D.04, subdivisions 2 and 3.

6. Violation: For one person whose record was reviewed (P4) the license holder did not review the need for the rights restriction as required.

The license holder implemented a rights restriction for P4 on April 6, 2023. The license holder failed to review the need for the restriction based on the conditions for ending the restriction semiannually from the date of initial approval.

Statute Violated: Minnesota Statutes section 245D.04, subdivision 3, paragraph (c).

7. Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not maintain information about, and report incidents as required.

a. P2 was involved in an incident on November 2, 2024. The license holder failed to:

· report this incident to P2’s case manager and legal representative within 24 hours. The license holder did not notify P2’s case manager and legal representative until November 5, 2024; and

· document the name of the staff person involved who responded to the incident and whether P2’s support plan addendum or program policies and procedures were implemented as applicable.

b. P4 was involved in an incident on March 7, 2024, that resulted in the use of a manual restraint. The license holder failed to verbally report the emergency use of manual restraint within 24 hours of occurrence to P4’s case manager.

c. P4 was involved in an incident on November 8, 2024, that resulted in a serious injury as defined by section 245.91, subdivision 6, clause (1). The license holder failed to:

· report the serious injury for P4 to the following within 24 hours of the serious injury:

o P4’s case manager;

o the Department of Human Services Licensing Division; and

o the Ombudsman for Mental Health and Developmental Disabilities.

· conduct an internal review of the serious injury that included an evaluation of:

o whether related policies and procedures were followed;

o whether the policies and procedures were adequate;

o whether there is a need for additional staff training;

o whether the reported event is similar to past events with the persons for the services involved; and

o whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services.

· based on the results of the internal review, develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff.

d. The license holder failed to enforce a written policy and procedure related to the reporting and review of incidents for incidents that involved P4 on March 7, 2024, and November 8, 2024. The license holder failed to complete an incident report no later than 24 hours after the incident occurred that included the following:

· the name of the person or persons involved in the incident;

· the date, time, and location of the incident;

· a description of the incident;

· a description of the response to the incident and whether a person’s support plan addendum or program policies and procedures were implemented as applicable;

· the name of the staff person or persons who responded to the incident; and

· the results of the review of the incident.

Statute Violated: Minnesota Statutes, section 245D.06, subdivision 1, and section 245D.11, subdivision 2, clause (7).

8. Violation: For three persons whose records were reviewed (P1-P2, and P4), the license holder did not meet the requirements for safekeeping and handling a person’s funds as required.

a. The license holder assisted P1 and P2 with safekeeping of funds. The license holder failed to survey, document, and implement the preferences of P1’s legal representative, P2’s legal representative, P1’s case manager, and P2’s case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds or other property.

b. The license holder assisted P4 with safekeeping of funds. The license holder failed to obtain written authorization from P4’s legal representative and case manager for the safekeeping of funds and property annually as required. The license holder obtained authorization on April 6, 2023, and May 29, 2024.

Statute Violated: Minnesota Statutes, section 245D.06, subdivision 4.

9. Violation: For two persons whose record was reviewed (P2 and P4), the license holder utilized prohibited procedures.

a. P2 was involved in an incident on November 2, 2024, that resulted in the use of a manual restraint. In an incident report dated November 3, 2024, the license holder documented the manual restraint was utilized as a behavioral program to eliminate P2’s behavior. The license holder failed to prohibit the use of a manual restraint as a behavioral or therapeutic program to eliminate behavior.

b. P4 was involved in an incident on March 7, 2024, that resulted in the use of seclusion. In an internal review dated April 12, 2024, the license holder documented that P4 was contained in an area for thirty minutes and P4 not allowed to leave the area as a behavioral program to eliminate P4's behavior. The license holder failed to prohibit the use of seclusion.

Statute Violated: Minnesota Statutes, section 245D.06, subdivision 5.

10. Violation: For one person whose record was reviewed (P4), the license holder did not ensure that emergency use of manual restraints complied with the requirements of this chapter.

a. P4 was involved in an incident on March 7, 2024, that resulted in the use of a manual restraint and law enforcement involvement. The license holder failed to:

· report in writing to the designated coordinator about the emergency use within three calendar days after an emergency use of manual restraint;

· complete and document an internal review within five working days of the emergency use of manual restraint;

· evaluate in the internal review whether the person’s service and support strategies developed according to section 245D.07 and 245D.071 need to be revised;

· consult with the expanded support team within five working days after the completion of the internal review to:

o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identified the perceived function the behavior served; and

o determine whether the person's support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint; and

· submit the following to the Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities within five working days of the expanded support team review:

o the report required under subdivision 5;

o the internal review and corrective action plan required under subdivision 6; and

o the summary of the expanded support team review required under subdivision 7.

Statute Violated: Minnesota Statutes, section 245D.061.

11. Violation: For two persons whose records were reviewed (P1 and P2), the license holder failed to provide services as assigned in the support plan and in compliance with the requirements of the federal waiver plan.

a. The license holder maintained a document in P1’s record regarding Disability Waiver Rate System exceptions that indicated the license holder was responsible for paying a higher wage for qualified direct support staff and providing additional training needed to attract qualified employees to work with P1. The license holder failed to provide services according to P1’s support plan, including paying staff according to the rate exception and providing staff training above the 245D requirements specific to the needs of the person.

b. The license holder maintained a document in P2’s record regarding Disability Waiver Rate System exceptions that indicated the license holder was responsible for:

· paying a higher wage for qualified direct support staff and additional training needed to attract qualified employees to work with P2;

· ensuring P2’s house supervisor would only supervise P2’s house; and

· ensuring the van used to transport P2 van would not be shared with other residents.

The license holder stated that these criteria were not met. P2’s house supervisor supervised more than P2’s house and P2 was transported with other residents; therefore, the license holder failed to provide services according to P2’s support plan.

Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1.

12. Violation: For three persons whose records were reviewed (P2-P4), the license holder did not provide services in response to the person’s identified needs, interests, and preferences as required.

a. The license holder failed to develop a support plan addendum that identified P2’s needs and interests:

· P2’s support plan addendum developed by the license holder documented that P2 was required to have a staff person always present in the home. The license holder maintained a log note in P2’s record dated January 5, 2025, documented P2 utilized “alone time.” SP2 stated P2 was left without staff supervision and that P2 did have alone time. This was inconsistent with the information in P2’s support plan addendum.;

· P2’s support plan addendum developed by the license holder stated that positive support strategies were not needed because P2 did not have behaviors that would pose an imminent risk of physical harm. This contradicted information provided in the assessments completed by the license holder and the Disability Waiver Rate System document; and

· P2’s support plan addendum developed by the license holder had the name of another service recipient in the document. DHS licensors could not determine if this plan was developed for P2.

b. P3’s support plan addendum developed by the license holder stated that P3’s staff will remain in visual eyesight of P3 at all times while at home. The license holder failed to provide the level of supervision required to meet P3’s needs when P3 accessed a locked room that stored medications and self-administered the medications. The license holder discovered that P3 accessed the locked room and self-administered medications on January 23, 2025.

c. P4’s support plan addendum developed by the license holder stated that P4 will have staff on site with them at all times and that staff will be within visual range of P4 at all times when out in the community. Staff were unaware that P4 eloped on December 1, 2024. In an internal review of the incident dated December 5, 2024, the license holder identified a pattern of incidents, stating that P4 “has done this several times before.” The license holder did not indicate P4’s pattern of elopement in P4’s assessments completed by the license holder. The license holder failed to develop a support plan addendum that identified P4’s needs.

Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a.

13. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not meet initial service planning requirements for intensive support services as required.

a. The license holder held P1’s initial planning meeting on May 10, 2024. The license holder failed to determine the following information:

· opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interest, and preferences;

· opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community;

· opportunities to seek employment and work at competitively paying jobs in the community; and

· a discussion of how technology might be used to meet the person’s desired outcomes including:

o 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.

b. The license holder held P4’s initial service planning meeting on April 6, 2023. The license holder failed to determine the following:

· 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 the person’s choice in the community; and

· opportunities to seek competitive employment and work at competitively paying jobs in the community.

Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3.

14. Violation: For three persons whose records were reviewed (P1-P2, and P4), the license holder did not develop service outcomes and supports as required.

a. The license holder held P1’s initial service planning meeting on March 25, 2024. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person-centered planning within ten days of the initial planning meeting for P1. The license holder developed P1’s service outcomes and supports on July 1, 2024.

Additionally, the license holder failed to document the following supports and methods for P1 to accomplish the outcome developed on July 1, 2024:

· the methods or action that will be used to support the person and to accomplish outcomes, including information about:

o any changes or modifications to the physical and social environments necessary when the service supports were provided;

o any equipment or materials required; and

o techniques that were consistent with the person’s communication mode and learning style;

· the measurable and observable criteria for identifying when the desired outcome had been achieved; and

· the names of the staff or position responsible for implementing the supports and methods.

b. The license holder failed to document the following for P2’s supports and outcomes:

· any changes of modifications to the physical and social environments necessary when the service supports were provided; and

· techniques that were consistent with P2’s communication mode and learning style.

c. The license holder held P4’s initial service planning meeting on April 6, 2023. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person-centered planning within ten days of the initial planning meeting for P4. The license holder developed the service outcomes and supports on May 10, 2023.

Additionally, P4’s support plan addendum the license holder developed identified one of P4’s support and outcomes as P4 will participate in exercise at least 3 times per week. The license holder failed to document the following supports and methods for P4 to accomplish this outcome:

· 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; and

· the names of the staff or position responsible for implementing the supports and methods.

Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4.

15. Violation: For one person whose record was reviewed (P4), the license holder did not meet the requirements for service plan review and evaluation as required.

The license holder failed to discuss options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider with P4, their legal representative and case manager, and members of the support team at least once per year. The license holder did not hold this discussion in 2024.

Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5.

16. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not maintain service recipient records as required.

a. The license holder failed to maintain an admission form that included P1’s current address in P1’s service recipient record.

b. The license holder failed to maintain written progress review reports in P4’s service recipient record.

Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3.

17. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not evaluate positive support strategies as required.

The license holder failed to evaluate with P3 and P4 the identified positive support strategies at least every six months.

Rule Violated: Minnesota Rules, part 9544.0030, subpart 1.

Health Service Needs Violations

18. Violation: For three persons whose records were reviewed (P2, P4-P5), the license holder did not document how health services would be met as required.

a. The license holder documented in P2’s support plan addendum that the license holder was responsible to monitor P2’s health conditions according to written instructions from a licensed health professional. The license holder failed to maintain written instructions from a licensed health professional on how to monitor these conditions.

Additionally, the license holder was responsible for assisting P2 with or coordinating medical, dental, and other health service appointments. The license holder failed to document how they would assist P2 with these appointments.

b. The license holder was assigned the responsibility of meeting P4’s health needs in P4’s support plan and support plan addendum, including providing medication administration and monitoring health conditions according to written instructions from a licensed health professional. P4 was prescribed a pro re nata (PRN) psychotropic medication. The license holder failed to maintain documentation on how P4’s health needs would be met in P4’s support plan addendum, including a description of the procedures the license holder would follow in order to administer P4’s PRN psychotropic medication.

Additionally, P4’s assessments dated July 19, 2024, that were completed by the license holder documented P4’s health condition. The license holder failed to maintain documentation on how the P4’s health needs would be met, including a description of the procedures the license holder would follow in order to monitor health conditions according to written instructions from a licensed health professional.

c. The license holder was assigned the responsibility of meeting P5’s health needs in P5’s support plan and support plan addendum. P5 was prescribed a pro re nata (PRN) psychotropic medication. The license holder failed to maintain documentation on how P5’s health needs would be met in P5’s support plan addendum, including a description of the procedures the license holder would follow in order to administer P5’s psychotropic PRN medication.

Statute Violated: Minnesota Statutes, section 245D.05 subdivision 1.

19. Violation: For four persons whose records were reviewed (P1, P3- P5), the license holder did not implement medication administration procedures as required.

a. The license holder maintained log notes for P1 that documented a PRN administration of melatonin to P1 on the following dates:

· October 14, 2024;

· October 21, 2024;

· October 26, 2024; and

· October 29, 2024.

The license holder failed to notate the administration of the medication in P1’s medication administration record (MAR) for the above-mentioned dates.

b. The license holder maintained log notes for P4 that documented a PRN administration of melatonin for P4 on September 14, 2024. The license holder failed to notate the administration of the medication in P4’s MAR.

c. The license holder failed to implement medication administration procedures to ensure P3 took medication and treatments as prescribed in the following ways:

· The license holder failed to notate when a medication was administered in P3’s MAR on February 1, 2025, February 2, 2025, and February 3, 2025.

· P3 was prescribed 300mg of Gabapentin to take each morning. P3 gained access to the room where P3’s medications were stored and P3 took several doses of 300mg Gabapentin. P3’s Gabapentin ran out on January 23, 2025. When P3’s staff discovered that the medication needed to be refilled, the pharmacy informed the staff that P3’s medication was not due to be refilled until February 3, 2025. The license holder failed to ensure P3 took medications as prescribed when P3 took additional doses of the 300mg of Gabapentin and when P3 did not receive the 300mg dose of Gabapentin from January 23, 2025, through February 3, 2025.

d. The license holder failed to implement medication administration procedures to ensure P5 took medications as prescribed in the following ways:

· As of February 4, 2025, P5 was prescribed 230mg of phenytoin (Dilantin) The license holder did not accurately document the prescription in P5’s MAR. The license holder documented in P5’sMAR that P5 was to be administered 630mg of phenytoin. The license holder administered the following doses of phenytoin to P5:

o 390mg on February 4, 2025;

o 560mg on February 5, 2025; and

o 330mg on February 6, 2025.

· P5 was prescribed senna-docusate on February 4, 2025. The license holder maintained medication administration records that indicated P5 was administered this medication on February 4, 2025 and February 5, 2025. DHS licensors observed that the licensed holder had not fulfilled the prescription with P5’s pharmacy.

Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2.

20. Violation: For four persons whose records were reviewed (P1, and P3-P5), the license holder did not review medication administration records and report medication treatment issues as required.

a. The license holder failed to ensure that the information maintained in P1’s, P4’s, and P5’s MARs were reviewed every three months, at a minimum, to ensure that the information was current and to identify medication administration errors. The license holder failed to review P1’s, P4’s and P5’s MARs at least every three months.

b. The license holder was assigned responsibility for medication administration for P3. The license holder documented medication errors between January 23, 2025, and February 3, 2025, where P3 did not receive a daily prescribed medication because it was unable to be refilled until February 4, 2025. The license holder failed to report the medication errors to P3’s case manager as they occurred. The license holder discovered the medication errors on January 23, 2025, and did not report the medication errors to P3’s case manager until January 30, 2025.

Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4.

21. Violation: For one person whose record was reviewed (P2), the license holder did not maintain documentation for an injectable medication as required.

The license holder was responsible for administering medications to P2. P2 was prescribed an EpiPen, an injectable medication. The license holder failed to ensure one of the following conditions were met:

· a registered nurse or licensed practical nurse will administer the injection;

· a supervising registered nurse with a physician’s order has delegated the administration of injectable medication to an unlicensed staff member and has provided the necessary training; or

· there is an agreement signed by the license holder, the prescriber, and the person or the person’s legal representative specifying what injections may be given, when, how and that the prescriber must retain responsibility for the licenser holder’s giving the injections.

Statute Violated: Minnesota Statutes, section 245D.05, subdivision 5.

22. Violation: For two persons whose records were reviewed (P1-P2), the license holder did not monitor the use of the psychotropic medications as required.

Target symptoms refer to any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation.

The license holder was assigned responsibility for administering P1’s and P2’s psychotropic medications. The license holder failed to maintain documentation of a description of the target symptoms for each psychotropic prescribed to P1 and P2.

Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b).

Staffing Standards Violations

23. Violation: For four of fifteen staff persons whose records were reviewed (SP2, SP3, SP4, and SP6), the license holder did not provide training on the prevention and reporting of maltreatment of vulnerable adults and the license holder’s program abuse prevention plan (PAPP) as required.

a. The license holder failed to provide orientation training to vulnerable adult maltreatment reporting to SP3 within 72 hours of first providing direct contact.

b. The license holder failed to provide orientation to SP3, SP4, and SP6 of the license holder’s program abuse prevention plan within 72 hours of first providing direct contact.

c. The license holder failed to provide SP2 with training on the license holder’s program abuse prevention plan annually in 2025. The license holder most recently provided this training to SP2 on January 30, 2024.

d. The license holder failed to provide SP4 training on vulnerable adult maltreatment reporting annually in 2025. The license holder most recently provided this training to SP4 on January 28, 2024.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3.

24. Violation: For four staff persons whose records were reviewed (SP2, SP3, SP4, and SP6), the license holder did not provide orientation training as required.

a. The license holder failed to provide SP2 and SP6 with training on the license holder policies and procedures for service suspension, and the license holder’s policy and procedures for emergency response, reporting and review.

b. The license holder failed to provide SP3 with the following trainings within 60 days of hire:

· service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, 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 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;

· 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;

· 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.

c. The license holder failed to provide SP4 with training on strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities within 60 days of hire.

Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4.

25. Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide annual training as required.

a. The license holder failed to provide SP3 with annual training in the following topic areas:

· 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. The license holder most recently provided SP3 with the training in April 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. The license holder most recently provided SP3 with the training in April 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. The license holder most recently provided SP3 with the training in April 2022;

· basic first aid. The license holder had not provided this training to SP3 at the time of the licensing review; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder had not provided this training to SP3 at the time of the licensing review.

b. The license holder failed to provide SP4 with annual training in the following topic areas:

Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5.

26. Violation: For three staff persons whose records were reviewed (SP2, SP3, and SP4), the license holder did not maintain personnel records as required.

a. The license holder failed to maintain a personnel record for SP2 that included training documentation, including the number of hours per subject area.

b. The license holder failed to maintain a personnel record for SP3 that included training documentation, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructors.

c. The license holder failed to maintain a personnel record for SP4 that included SP4’s date of hire.

d. The license holder failed to maintain documentation in SP3’s and SP4’s personnel record or elsewhere, sufficient to determine the date of each employee’s first supervised and unsupervised direct contact with a person served by the program.

Statute Violated: Minnesota Statutes, section 245D.095, subdivision 5.

Policy and Procedure Violations

27. Violation: For one person whose record was reviewed (P4), the license holder did not enforce a written policy and procedure related to suspected or alleged maltreatment as required.

The license holder failed to enforce the program’s policies and procedures related to suspected or alleged maltreatment when P4 was involved in an incident that occurred on November 8, 2024. The license holder failed to:

· report suspected or alleged maltreatment;

· complete an “Incident and Emergency Report,” according to the requirements in section 245D.11, subdivision 2, paragraph (7); and

· inform P4’s case manager, within 24 hours of reporting maltreatment as required under section 626.557, of the report, including the nature of the activity or occurrence reported and the agency that received the report according to section 245D.06, subdivision 1, paragraph (d).

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1.

28. Violation: For one person whose record was reviewed (P5), the license holder did not enforce and maintain policies and procedures for safe medication administration as required.

a. The license holder failed to update their medication administration policy, including procedures for medication documentation and charting, to reflect the electronic record keeping and documentation system the program implemented in August 2020.

b. The license holder’s medication administration policy stated, “staff will, beginning with the highest number, push the correct dose [from the bubble pack] into a medication cup, and write the date and their initials on the card next to the dose popped out.” At the time of the licensing review, DHS licensors observed that the license holder failed to enforce this policy through observation of P5’s medications and medication administration records.

Statute Violated: Minnesota Statutes, section 245D.11, subdivision 2.

Immediate corrective action required

You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite ongoing. If you fail to demonstrate substantial compliance with home and community-based services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license.

Nature, chronicity, or severity of violations and effective of violations(s) on health, safety, or rights of persons served by the program

The Commissioner considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violations on the health, safety or rights of persons served by the program. Based on this analysis, your license will be placed on a conditional status.

· Nature: DHS determined you were responsible for 28 licensing violations related to the health, safety, and rights of the persons served.

· Chronicity: Your program received its license on January 1, 2014. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history:

o April 22, 2025: Conditional License (this order): 28 Violations

o April 17, 2025: Order to Pay a Fine, Failure to Report

Maltreatment $200 fine

o April 3, 2025: Order to Pay a Fine: Background Study Violation $200 Fine

o March 5, 2025: Determinations of Maltreatment,

Failures to Report Maltreatment, and Order to Pay a Fine: 5 Determinations, 4 Failures to Report, $5,800 fine

o February 12, 2025: Correction Order: 3 Violations

o February 12, 2025: Correction Order: 1 Violation

o November 21, 2024: Correction Order: 1 Violation

o September 25, 2024: Correction Order: 2 Violations

o September 27, 2023: Correction Order: 1 Violation

o October 13, 2022: Correction Order: 1 Violation

o May 17, 2022: Correction Order: 2 Violations

o September 28, 2021: Correction Order: 3 Violations

o June 15, 2021: Correction Order: 3 Violations

o June 10, 2021: Correction Order: 4 Violations

o October 8, 2020: Correction Order: 11 Violations

o November 22, 2019: Correction Order: 4 Violations

o November 8, 2019: Correction Order: 4 Violations

o September 16, 2019: Correction Order: 11 Violations

o June 21, 2019: Correction Order: 4 Violations

o June 10, 2019: Correction Order: 4 Violations

o May 16, 2019: Correction Order: 7 Violations

o November 19, 2018: Correction Order: 5 Violations

o November 2, 2018: Correction Order: 4 Violations

o October 26, 2018: Correction Order: 3 Violations

o September 13, 2018: Correction Order: 5 Violations

o August 31, 2018: Correction Order: 1 Violation

o August 21, 2018: Correction Order: 5 Violations

o August 17, 2018: Correction Order: 3 Violations

o June 22, 2018: Correction Order: 5 Violations

o November 7, 2017: Correction Order: 7 Violations

o October 31, 2016: Correction Order: 10 Violations

o June 27, 2016: Licensing Review Report: 0 Violations

o June 21, 2016: Correction Order: 1 Violation

o October 29, 2015: Correction Order: 9 Violations

o June 22, 2015: Correction Order: 8 Violations

· Severity: Many of the violations involve your failure to properly document and review medication administration responsibilities, which could affect the health and safety of the persons served. You failed to document an individualized description of the procedures to provide medication administration; did not make notation when medications were administered; or conduct medication reviews to identify and correct medication errors. Failing to ensure service recipients receive the necessary health services and medication may have resulted in significant health complications from those who are dependent on the competent assistance of the license holder to ensure their health needs are met.

You did not develop individual abuse prevention plans that included specific measures to be taken to reduce the risk of abuse to the person, which could negatively impact the health and safety of persons served. Individual abuse prevention plans provide staff with knowledge of potential risks and proactive or reactive strategies to reduce the risk. By not including specific measures to be taken in the individual abuse prevention plans, you did not ensure staff had knowledge of the specific measures to be taken to reduce the risk of abuse, thereby putting the health and safety of the persons you served at risk.

License holders are required to ensure the exercise and protection of the rights of persons served by your program. You restricted persons rights to have a clean and safe home, have visitors and to have access to personal possessions. A CRS you operated (license number 1070371) had a storage room where dried food, incontinence supplies, and a person’s clothing was stored. This room was infested with rodents and the rodents chewed into the bags of dried food and the clothing. Your failure to ensure the exercise and protection of persons rights limited their ability to receive services in the least restrictive way and put persons health, safety and well-being at risk.

The designated coordinators and designated managers failed to provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your program remains in compliance with licensing requirements. The requirement to identify and hire a qualified designated coordinator and designated manager is an essential function of a license holder due to the importance of these positions in providing program management and oversight of the services provided to persons served. These roles are responsible for understanding licensing requirements sufficient to ensure compliance throughout the program. As a result of your failure to ensure the designated coordinators and designated managers provided program coordination, evaluation and oversight, you were found in violation of the 28 citations described in this order.

The license holder failed to provide orientation and annual training to direct support staff persons, including training on maltreatment reporting requirements. When direct support staff are not provided with orientation and annual training, staff may not be competent to provide services to persons and there is an increased risk of neglect or abuse to persons served by the program. As a result of your failure to train staff, the use of prohibited procedures for behavioral or therapeutic program to reduce or eliminate behavior, including manual restraint and seclusion, was implemented. Training staff is a critical part of ensuring persons served are kept safe and to ensure their rights are protected. The failure to provide staff training directly relates to health, safety, and well-being of persons served by the program.

The license holder allowed a staff person to have direct contact after you were notified by DHS of the staff person’s disqualification. Allowing an individual to work without a cleared background study puts those served at risk of harm because DHS has evaluated the direct support staff’s criminal history and determined the staff is disqualified from providing direct support services. Further, the inability to remove disqualified individuals at the direction of DHS calls into question the program’s ability to follow the applicable laws and rules; to be able to operate a program; and to ensure the well-being of persons served.

Commissioner’s evaluation of program

In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of:

· the program’s operation;

· well-being of persons served by your program;

· available evaluations of the program by persons receiving services;

· information about the qualifications of the direct support staff employed by you;

· the ability to demonstrate competent knowledge of applicable laws and rules; and

· the results of background studies.

DHS is concerned about your program’s operation, well-being of persons served by your program, qualifications of staff, your ability to demonstrate competent knowledge of applicable laws, and the results of background studies. DHS is concerned about your program’s operation because since you were licensed in 2014, DHS has issued 31 correction orders, determinations of maltreatment and failures to report maltreatment, 3 orders to pay a fine, and 28 licensing violations determined during the most recent licensing review. The number of violations demonstrates that you failed to adequately oversee your responsibilities as a license holder, to ensure compliance, and take corrective action when ordered by the Commissioner. DHS’ concerns about your program’s operation and ability to demonstrate competent knowledge were also demonstrated in your failure to train staff and by allowing a staff person with a disqualified background study to provide direct support services to persons served by your program. These failures pose a risk to the well-being of persons served by your program and present a concern that staff providing services are not qualified to provide services to vulnerable adults in ways that meet each vulnerable adult’s unique needs.

You did not comply with service planning and record keeping requirements. These requirements protect the health and safety of persons served and are minimum standards for license holders. Failure to comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Record keeping and service planning requirements are essential to keeping vulnerable adults safe and ensuring persons served are receiving necessary services. Your lack of service planning and documentation posed a risk that staff would not know about the unique needs of the vulnerable people served.

DHS has determined that an Order of Conditional License is appropriate based on the violations identified above and the program evaluation.

Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6.

Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services is placed on a conditional status.

Order applies to all 245D service sites

This Order of Conditional License applies to all your 245D service sites, including all community residential facilities (CRS), any location where 245D services are being delivered that are owned, leased, a person’s own home or the community. The 28 violations show you lack competent knowledge of the laws required to operate an HCBS program. Since the 28 violations involved your lack of competence to hire and train competent designated coordinators and designated managers, they involved multiple staff, and persons served at multiple service sites, and they were serious in nature, this conditional order applies to all your 245D service sites.

CONDITIONAL LICENSE TERMS

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 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 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 participant and staff records for compliance with all applicable rules and statutes.

· Submit documentation that your program’s designated coordinators and designated managers have reviewed and acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3

3. Within 60 days of receiving this order, you must:

· Complete an audit of all participant and personnel records according to your written plan.

· Submit the results to your DHS licensor.

· Submit the date to your DHS licensor when all participant 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.

· Review all incidents from October 1, 2024, through current, for suspected or alleged maltreatment, including the incident identified in citation numbers 7 and 28 that occurred on November 7, 2024. You must report any incidents of suspected or alleged maltreatment as required. You must maintain documentation of this review of incidents and any maltreatment reports you make as a result of this review.

4. You may not admit new participants to your program without prior written approval from DHS Licensing; from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. Program is defined by section 245D.02, subdivision 26 meaning either the nonresidential or residential programs as defined in 245A.02, subdivisions 10 and 14.

5. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. You may continue with the two in-process applications you have with Anoka County for a child foster residential setting (CFRS) and Hennepin County for a community residential setting (CRS).

6. You may not add additional services to your HCBS license without prior approval from DHS for the duration of this conditional license.

Submissions required as part of a corrective action ordered must be sent to your DHS licensor at:

1. By secure email at lacey.l.walsvik@state.mn.us; or

2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below:

Commissioner, Department of Human Services

ATTN: Lacey Walsvik

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

· Clearly state that you are requesting reconsideration of the conditional license

· List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· State why you believe your license should not be on a conditional status

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Conditional license stayed pending reconsideration

If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all HCBS laws and rules.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4.

· If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4.

· Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order.

Questions

If you have any further questions regarding this matter, you may contact Renae Dressel, Supervisor, at 651-431-2661.

Sincerely,

Christala Culhane, Unit Manager

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/