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June 24, 2025 Akawak Regassa, Authorized Agent Marvelous Care For All 10986 Pierce Street Northeast Blaine, Minnesota 55434 License Number: 1111234 (245D – HCBS) CORRECTION ORDER Dear Akawak Regassa: On May 21, 2025, a licensing review of Marvelous Care For All, located at 1935 Park Avenue Unit 301 Minneapolis, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one of two persons whose record was reviewed (P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP as part of the initial individual program plan or service plan. The license holder initiated P2’s services on May 3, 2023, and the license holder developed P2’s IAPP on June 14, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not meet health service needs as assigned. The license holder was assigned the responsibility of monitoring P1’s blood sugar levels. The license failed to maintain documentation on how the person’s health needs will be met including a description of the procedures the license holder will follow in order to monitor P1’s blood sugar levels according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must document in P1’s record a description of the procedures you will follow in order to monitor P1’s blood sugar levels. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For one person whose record was reviewed (P1), the license holder did not document medication setup services as required. The license holder was setting up P1’s medications weekly. The license holder failed to document the date of medication setup in P1’s medication administration record. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not document in the medication administration record (MAR) as required. The license holder failed to ensure information on any risks or other side effects that are reasonable to expect, and any contraindication to its use was documented in P1’s MAR. Corrective Action Ordered: Within 30 days of receiving this order, you must document in P1’s MAR the above-mentioned information and the information must be readily available to all staff administering medications. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose record was reviewed (SP1), the license holder did not provide orientation as required. The license holder hired SP1 on December 3, 2022. The license holder failed to provide SP1 orientation within 60 calendar days of hire in the following areas: · The job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06 subdivision 1. The orientation to the job description was provided to SP1 on May 1, 2023, and the orientation on responding and reporting incidents was provided to SP1 on February 5, 2023; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2. This was not provided to SP1. · the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures. This was provided to SP1 on February 17, 2023; · 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. This was provided to SP1 on February 5, 2023; · 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. This was provided to SP1 on February 5, 2023; · 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. This was provided to SP1 on February 5, 2023; · 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. This was provided to SP1 on February 5, 2023; · 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 why such procedures are not safe. This was provided to SP1 on February 5, 2023; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. This was provided to SP1 on February 5, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with orientation to following safety practices as required in 245D.06, subdivision 2 and maintain documentation of this orientation in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. 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 provide 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 with annual training in 2024 when the license holder provided training on the following topics to SP1 in February 2023 and March 2024: · 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. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · 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 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; · 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 why such procedures are not safe; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.
b. The license holder failed to provide SP2 with annual training on basic first aid in 2024. This was provided to SP2 on May 10, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of SP2’s training in SP2’s personnel record that included the number of hours per subject area and the name of the trainer or instructor for each subject area. 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 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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