May 09, 2025

Angeline Walker

4 ABC Home Care Services

3300 County Road 10, Suite 320D

Brooklyn Center, MN 55429

1103859 (245D – Home and Community-Based Services)

CORRECTION ORDER

Dear Angeline Walker:

On April 15, 2025, a licensing review of 4 ABC Home Care Services located at 3300 County Road 10, Suite 230D, Brooklyn Center, MN 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 one of two persons whose record was reviewed (P2), the license holder did not provide orientation to the policies and procedures related to suspected or alleged maltreatment as required.

The license holder failed to provide P2 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· provide the above orientation to P2;

· audit all persons served records to ensure the above orientation has been provided; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. 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 establish written individual abuse prevention plans (IAPP) as required.

a. The license holder failed to develop an IAPP for P1 as part of the initial individual program or service plan.

b. The license holder developed an IAPP for P2 that assessed that P2 was not susceptible to abuse, however; this was inconsistent with information elsewhere in P2’s record. P2’s support plan dated July 7, 2023, documented that P2 was susceptible to physical abuse, self-abuse, and financial abuse.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· develop an IAPP for P1;

· review and revise P2’s IAPP to document all areas of abuse P2 is assessed as being susceptible to;

· audit all person served records to ensure that all areas where each person is susceptible to abuse is documented in that person’s IAPP as required in this section; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (b) and (c).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet service planning requirements for basic support services as required.

a. The license holder failed to complete a preliminary support plan for P1 within 15 calendar days of service initiation for 24-hour emergency assistance.

b. The license holder failed to review and revise P1’s support plan addendum within 60 days of service initiation for individualized home supports with training to document the services that would be provided including how, when, and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services.

c. The license holder initiated the services of individualized home supports with training and employment development services with P2 on August 12, 2024. The license holder failed to complete a preliminary support plan addendum for P2 within 15 calendar days of initiation for individualized home supports with training.

The license holder initiated individual home supports on October 29, 2024. The license holder failed to complete a preliminary support plan addendum for P2 within 15 calendar days of initiation for individualized home supports.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· develop a preliminary support plan addendum for P1 for 24-hour emergency assistance;

· review and revise P1’s support plan addendum for individualized home supports with training to document the requirements above;

· develop a preliminary support plan addendum for P2 for individualized home supports;

· audit all person served records to ensure the requirements above have been developed and/or reviewed and revised as needed; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.07, subdivision 3.

Violation: For one person whose record was reviewed (P1), the license holder did not provide written reports as required.

The license holder failed to provide written reports regarding P1’s progress or status as required. The license holder documented in P1’s support plan addendum that progress reports and recommendations would be provided quarterly to P1 and P1’s case manager. There were no reports in P1’s record.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete assessments as required.

a. The license holder failed to complete assessments for P1 for employment development services in the following areas before providing 45 days of service or within 60 calendar days of service initiation:

· the person'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;

· the person'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

· the person'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 the person or others.

b. The license holder failed to complete assessments for P2 for employment development services in the following areas before providing 45 days of service or within 60 calendar days of service initiation:

· the person'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;

· the person'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

· the person'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 the person or others.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· complete the required assessments for P1 and P2;

· audit all person served records who receive intensive services to ensure the above has been completed, and the assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms; and

· maintain documentation of audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (a) and (c).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for service planning and delivery for intensive support services as required.

a. The license holder failed to complete a preliminary support plan addendum for P1 and P2 within 15 calendar days of service initiation for employment development services.

b. The license holder failed to hold an initial service planning meeting with P1, P1’s case manager and other members of P1’s support team or expanded support team, and other people as identified by P1 before providing 45 days or service or within 60 days of service initiation to determine:

· the scope of services to be provided to support the person’s daily needs and activities;

· the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes;

· the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule;

· whether the current service setting is the most integrated setting available and appropriate for the person;

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

· opportunities for community access, participation, and inclusion preferred community activities;

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

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

· 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 continuity of care and coordination of services for the person; and

· a discussion of how technology might be used to meet the person's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include:

o a statement regarding any decision that is made regarding the use of technology; and

o a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

c. The license holder failed to hold an initial service planning meeting with P2, P2’s case manager and other members of P2’s support team or expanded support team, and other people as identified by P1 before providing 45 days or service or within 60 days of service initiation to determine:

· the scope of services to be provided to support the person’s daily needs and activities;

· the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes;

· the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule;

· whether the current service setting is the most integrated setting available and appropriate for the person;

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

· opportunities for community access, participation, and inclusion preferred community activities;

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

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

· 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 continuity of care and coordination of services for the person; and

· a discussion of how technology might be used to meet the person's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include:

o a statement regarding any decision that is made regarding the use of technology; and

o a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· hold a meeting with P1, P1’s case manager and other members of P1’s support team or expanded support team, and other people as identified by P1 to determine the above;

· hold a meeting with P2, P2’s case manager and other members of P2’s support team or expanded support team, and other people as identified by P2 to determine the above;

· audit all person served records who receive intensive services to ensure the above has been completed; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. 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 service outcomes and supports as required.

The license holder failed to develop a service plan for P1 and P2 that documented the service outcome and supports.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· develop service outcomes and supports for P1 and P2;

· audit all person served records who receive intensive services to ensure the above has been developed; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. 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 provide written or electronic copies of policies and procedures as required.

a. The license holder failed to inform and provide copies of the following policies and procedures affecting a persons’ rights to P1’s case manager within five days of service initiation:

· grievance policy;

· service suspension policy;

· service termination policy;

· emergency use of manual restraint policy; and

· data privacy.

This was provided to P1’s case manager on April 9, 2025.

b. The license holder failed to inform and provide copies of the following policies and procedures affecting a persons rights to P2 and P2’s case manager within five days of service initiation of individualized home support with training and employment development services:

· grievance policy;

· service suspension policy;

· service termination policy;

· emergency use of manual restraint policy; and

· data privacy.

Additionally, the license holder failed inform and provide copies of the following policies and procedures affecting a persons right to P2 and P2’s case manager within five days of service initiation of individualized home supports:

· grievance policy;

· service suspension policy; and

· service termination policy.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· inform and provide copies of the policies and procedures affecting a person’s rights to P2 and P2’s case manager;

· audit all person served records to ensure the above has been provided; and

· maintain documentation of the audit results.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.095, subdivision 2.

Violation: The license holder did not keep an admission and discharge record as required.

The license holder failed to keep a written or electronic register, listing in chronological order the dates and names of all persons served in the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder or deaths.

Corrective Action Ordered: Within 60 days of receiving this order you must keep an admission and discharge register that meets the above requirements. Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Rules, part 9544.0030, subpart 1.

Violation: For one person whose record was reviewed (P1), the license holder did not evaluate positive support strategies as required.

The license holder failed to review and evaluate the identified positive support strategies with P1 at least every six months.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and evaluate the identified positive support strategies with P1;

· based upon the results of the evaluation determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes;

· audit all person served records to ensure the above has been evaluated; and

· maintain documentation of the audit results.

On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Rules, part 9544.0080, subpart 1.

Violation: For one person whose record was reviewed (P2), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required.

The license holder failed to obtain a written acknowledgement from P2 indicating that P2 had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, sect 245D.04.

  Corrective Action Ordered: Within 60 days of receiving this order, you must:

· obtain written acknowledgement from P2 that they were notified of your policy on emergency use of manual restraint; and

· audit all person served records to ensure the above has been completed for each service recipient as required.

Corrective action will be monitored at an upcoming licensing visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For one of four staff persons whose records were reviewed (SP1), the license holder did not provide orientation to Vulnerable Adult (VA) maltreatment reporting as required.

The license holder failed to ensure SP1 received orientation to VA maltreatment reporting within 72 hours of first providing direct contact services as required.

Corrective Action Ordered: Immediately upon receiving this order, you must provide orientation to VA maltreatment reporting to SP1.

Additionally, within 60 days of receiving the order, you must:

· audit all staff personnel records to ensure the above has been provided; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed onsite 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.09, subdivision 4.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide and ensure completion of orientation training as required.

SP1’s hire date was December 30, 2024. The license holder failed to ensure SP1 received orientation training on the following topics within 60 calendar days of hire:

· grievance and complaint policy and procedure;

· temporary service suspension policy and procedure;

· service termination policy and procedure;

· prohibition on drug and alcohol use policy and procedure;

· emergency use of manual restraint policy and procedure;

· use of universal precautions and sanitary practice policy and procedure;

· safe transportation policy and procedure;

· service admission policy and procedure; 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.

SP2’s hire date was May 15, 2024. The license holder failed to ensure SP2 received orientation training on the following topics within 60 calendar days of hire:

· grievance and complaint policy and procedure;

· temporary service suspension policy and procedure;

· service termination policy and procedure;

· prohibition on drug and alcohol use policy and procedure;

· use of universal precautions and sanitary practice policy and procedure;

· safe transportation policy and procedure;

· service admission policy and procedure; 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.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· provide SP1 and SP2 with the above orientation training topics;

· maintain documentation of this training in SP1’s and SP2’s personnel records;

· audit all staff personnel records to ensure all required orientation training has been provided; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed onsite 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.09, subdivision 4a, paragraph (a).

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required.

The license holder failed to provide SP1 and SP2 with the following training within 60 calendar dates of hire:

· the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and

· the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· provide SP1 and SP2 with the above-mentioned orientation training topics;

· maintain documentation of this training in SP1’s and SP2’s personnel records;

· audit all staff personnel records to ensure all staff persons have received orientation training on individual service needs for every person they provide services to; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed onsite 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 2, paragraph (2).

Violation: The license holder did not establish policies and procedures as required.

The license holder failed to document the person with the highest level of authority, including name, address, and telephone, within the grievance policy.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· update your grievance policy to accurately reflect the person with the highest authority;

· provide notice to all persons served, their legal representatives if applicable and case managers, that meets the requirements of 245D.10, subdivision 4, paragraph (c); and

· inform and provide training to all staff persons as required in 245D.10, subdivision 4, paragraph (d).

Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.081, subdivisions 1 and 2.

Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight.

a. The license holder failed to ensure that the staff person the license holder identified as the designated coordinator met the following responsibilities:

· coordination of service delivery and evaluation for each person served by the program as identified in subdivision 2; and

· program management and oversight that includes evaluation of the program quality and program improvement for services provided by the license holder as identified in subdivision 3.

b. The license holder failed to ensure that the staff person the license holder identified as the designated coordinator 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 for identifying when the desired 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.

The failure to provide program coordination and oversight of the services is evidenced in citations 1 through 14.

  Corrective Action Ordered: Within 30 days of receiving this order, you must:

· designate a person other than SP3 or SP4 to be appointed as the designated coordinator, who is responsible for delivery and evaluation of services provided by the license holder;

· submit the name, contact information and qualifications of the person(s) you have designated and have ensured is competent to perform the duties of the designated coordinator as required in this section; and

· submit a signed acknowledgement that the newly designated person has reviewed and understands the responsibilities of a designated coordinator according to 245D.081, subdivision 2, paragraph (a).

On an ongoing basis, you must maintain compliance as required in this subdivision.

17. Citation: Minnesota Statutes, section 245D.081, subdivision 3.

Violation: The license holder did not ensure that the designated managerial staff person provided program management and oversight of the services provided as required.

The license holder failed to ensure the staff person the license holder identified as the designated manager met the following responsibilities:

· 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 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 toward 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; and

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

The failure to provide program management and oversight of the services is evidenced in citations 1 through 14.

  Corrective Action Ordered: Within 30 days of receiving this order, you must:

· designate a person, other than SP3 and SP4 to be appointed as the designated manager, who is responsible for delivery and evaluation of services provided by the license holder;

· submit the name, contact information and qualifications of the persons(s) you have designated and ensured is competent to perform the duties of the designated manager as required in this section; and

· submit a signed acknowledgement that the newly designated person has reviewed and understands the responsibilities of designated manager according to 245D.081, subdivision 3, paragraph (a).

On an ongoing basis, you must maintain compliance as required in this subdivision.

If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64953

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Kathleen “Katie” Crowley, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-2631

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