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June 9, 2025 Lori Wright, Authorized Agent NHS Northstar Inc 227 West Lake Street Suite 1 Chisholm, Minnesota 55719-3713 License Number: 1069654 (245D – HCBS) 1069668 (HCBS- Community Residential Setting) Investigation Report Number: 202410579 CORRECTION ORDER Dear Lori Wright: On June 9, 2025, a licensing complaint investigation of NHS Northstar Inc, located at 227 West Lake Street Chisholm, 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 245D.05, subdivision 1. Violation: For one of one person whose record was reviewed (P1), the license holder did not meet health service needs as required. The license holder was assigned the responsibility of assisting with and coordinating medical appointments for P1. After visit summaries from P1’s emergency room visits stated the license holder was to coordinate follow up with P1’s primary care physician. The license holder failed to meet the assigned health needs for P1 by not scheduling medical appointments for P1 after emergency room visits on these dates: · May 25, 2024; · June 29, 2024; and · August 2, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a plan of how you will maintain compliance with this subdivision to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.06, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not maintain information and report incidents as required. a. The license holder failed to maintain information about an incident as defined in 245D.02, subdivision 11 with P1 that occurred on August 2, 2024. b. P1 was involved in incidents that resulted in serious injuries on May 25, 2024, and August 2, 2024. The license holder failed to report P1’s serious injuries to the Department of Human Services Licensing Division and the Office of the Ombudsman for Mental Health and Developmental Disabilities within 24 hours of these incidents. Additionally, the license holder failed to conduct an internal review for the incident on August 2, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a plan of how you will maintain compliance with this subdivision to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: The license holder did not provide program coordination and evaluation as required. The license holder failed to ensure the designated coordinator, SP1, provided coordination of service delivery and evaluation for persons served by the program. See citations 1 and 2 for the designated coordinator’s failure to provide supervision, support, and evaluation of activities that included the oversight of the license holder’s responsibilities assigned in the person’s support plan and the support plan addendum. Corrective Action Ordered: SP1 is no longer the designated coordinator for this program. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not provide program management and oversight as required. The license holder failed to ensure the designated manager, SP2, provided program management and oversight of the services provided by the license holder. See citations 1 through 3 for the designated manager’s failure to: · maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program; · ensure the duties of the designated coordinator are fulfilled; and · ensure the program implements corrective action identified as necessary by the program following review of incident and emergency reports according to the requirements in section 245D.11, subdivision 2, clause (7). Corrective Action Ordered: Within 30 days of receiving this order, you must submit to this licensor a plan for how you will come into compliance with this subdivision. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at katie.gillman@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Katie Gillman Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Katie Gillman, HCBS Licensor Licensing Division Office of Inspector General 651-431-2656
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