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May 28, 2025 Gemeda Elemo Argo, Authorized Agent Gemeda E. Argo 12345 3rd Street Northeast Blaine, Minnesota 55434-1982 License Number: 1102371 (245D – HCBS) 1097021 (Adult Foster Care) CORRECTION ORDER Dear Gemeda Elemo Argo: On April 22, 2025, a licensing review of Gemeda E. Argo, located at 12345 3rd Street Northeast, Blaine, 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 one person whose record was reviewed (P1), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder initiated services for P1 on April 13, 2023. The license holder failed to develop an accurate IAPP for P1 as part of the initial individual program plan that included: · an individualized assessment of P1’s susceptibility to abuse by other individuals including other vulnerable adults and P1’s risk of abusing other vulnerable adults; · the statements of specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults; and · the specific actions the license holder would take to minimize the risk of abuse to P1 within the scope of licensed services. Although the license holder completed an initial IAPP, the information contained in the initial IAPP was not consistent with information found elsewhere in P1’s plan. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not implement medication administration procedures as required. The license holder failed to appropriately administer medications to P1 including: · checking P1’s medication record; · preparing P1’s medication as necessary; · administering P1’s medication; and · documenting the administration of P1’s medication accurately. P1’s medication administration record documented that P1 was administered Vitamin D daily in April 2025. At the time of the licensing review, the license holder did not have Vitamin D available, and the license holder was unable to determine the date the medication was last available and administered. Additionally, P1 was prescribed three medications to be administered twice per day. However, the license holder maintained a medication administration record that documented that these medications were administered once per day throughout April 2025. The license holder stated that these medications were administered as prescribed but did not document the administration of the medications to P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · report the medication errors to P1’s legal representative and case manager and maintain documentation of the notification in P1’s service recipient record; and · provide training to all staff on medication administration policies and procedures and maintain documentation according to Minnesota Statute 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance 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 complete initial intensive service planning as required. The license holder failed to have a discussion at the initial planning meeting with P1, P1’s legal representative, and P1’s case manager of how technology might be used to meet P1’s desired outcomes. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop service outcomes and supports as required. The license holder failed to document the supports and methods to be implemented to support P1 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being including: · the methods or actions that would 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; and o techniques that are consistent with P1’s communication mode and learning style; and · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data would be collected. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s service plan to include the requirements outlined above. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P1), the license holder did not complete an intensive service plan review as required. a. The license holder failed to at least once per year in 2024 discuss with P1, P1’s legal representative, and P1’s case manager how technology could be used to meet P1’s desired outcomes, and any further research that needed to be completed before a decision regarding the use of technology could be made. b. The license holder failed to at least once per year in 2024 discuss with P1, P1’s legal representative, and P1’s case manager the options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose records were reviewed (SP1), the license holder did not ensure orientation of mandated reporters as required. The license holder failed to provide and ensure completion of an orientation to the license holder’s program abuse prevention plan (PAPP) for SP1. Corrective Action Ordered: Immediately upon receiving this order, you must provide SP1 with an orientation to your PAPP and you must maintain documentation of SP1 receiving this orientation in the personnel record as required. Within 30 days of receiving this order you must: · audit all personnel records for documentation of orientation to the PAPP within 72 hours of providing direct contact to persons served and annual review of the PAPP as required. The results of the audit must be maintained in the program records for review by DHS licensors.; · immediately provide the missing training to any staff identified in the audit to be missing orientation or annual training to the PAPP; and · maintain documentation of this orientation or annual training in the personnel record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For one staff person whose record was reviewed (SP1), the license holder did not ensure completion of orientation as required. a. The license holder failed to provide SP1 with instruction on the license holder’s current policies and procedures required under this chapter, including their location, access, and staff responsibilities related to implementation of those policies and procedures. b. The license holder failed to provide SP1 with medication administration training that incorporated an observed skill assessment conducted by the trainer to ensure SP1 demonstrated the ability to safely and correctly follow medication procedures. c. The license holder failed to provide SP1 and SP2 with instruction on mental health crisis response, de-escalation techniques and suicide intervention when providing direct support to a person with a serious mental illness. Corrective Action Ordered: Within 30 days of receiving this order, you must: · audit all personnel records to ensure the above training has been completed. The results of the audit must be maintained in the program records for review by DHS licensors; · provide SP1 and staff identified in the audit with medication administration training from a training curriculum developed by a registered nurse or appropriate licensed health professional that incorporates an observed skill assessment; · provide SP1 and staff identified in the audit with instruction on the license holders current policies and procedures, including their location, access, and staff responsibilities related to implementation of those policies and procedures; · provide SP1, SP2, and staff identified in the audit with instruction on mental health crisis response, de-escalation techniques and suicide intervention; and · maintain documentation of the training provided including the date it was completed, the number of hours per subject area, and the name of the trainer or instructor in the personnel record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not ensure completion of annual training 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 failed to provide SP1 and SP2 with annual training in 2024 in the following 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 service recipient rights, and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 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 principles of person-centered 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 safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and such procedures are not safe. SP1 was hired April 27, 2023. The license holder did not provide training to SP1 on these topics on or before April 30, 2024. SP2 was hired April 12, 2023. The license holder did not provide training to SP2 on these topics on or before April 30, 2024. b. The license holder failed to provide SP1 and SP2 with annual training in 2024 on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder did not provide training to SP2 on this topic on or before April 30, 2024. At the time of the review, SP1 had not received this training. Corrective Action Ordered: Within 30 days of receiving this order, you must provide and ensure completion of training on minimizing the risk of sexual violence, including the concepts of healthy relationships, consent, and bodily autonomy of people with disabilities to SP1. Documentation of this training including the date of completion, number of hours per subject area, and the name of the trainer or instructor must be maintained in the personnel record as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain documentation of SP1’s orientation to individual service recipient needs including the date of orientation, number of hours per subject area, and name of the trainer or instructor in SP1’s personnel record as required. Corrective Action Ordered: 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 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Erin White, Home and Community Based Services Licensor Licensing Division Office of Inspector General 651-431-4821
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