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June 23, 2025 Jimmy Ogunsina, Authorized Agent Allied Health Services 4368 122 Circle Northeast Blaine, Minnesota 55449-2103 License Number: 1106726 (245D – HCBS) CORRECTION ORDER Dear Jimmy Ogunsina: On May 9, 2025, a licensing review of Allied Health Services, located at 4368 122 Circle 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 1. Violation: For one of one person whose record was reviewed (P1), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder provided multiple services to P1. The license holder initiated P1’s individualized home supports with training service on May 4, 2021, and initiated P1’s 24 hour emergency assistance service on April 10, 2023. The license holder failed to provide P1 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of each service admission. The license holder provided P1 with an orientation to P1’s individualized home supports with training service on May 6, 2022. Corrective Action Ordered: Within 60 days of receiving this order, you must provide an orientation to the internal and external reporting procedures to P1 for P1’s 24 hour emergency assistance service. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1 as part of the initial individual plan or service plan. The license holder initiated P1’s individualized home supports with training service on May 4, 2021, and developed an IAPP for P1 on March 25, 2025. Additionally, the license holder failed to develop an IAPP for P1 as part of the initial individual plan or service plan for P1’s 24 hour emergency assistance service Corrective Action Ordered: Within 60 days of receiving this order, you must develop an IAPP for P1’s 24 hour emergency assistance service. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), 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 failed to provide P1 a written notice that identified the service recipient rights and an explanation of those rights in 2022, 2023, and 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1 a written notice that identified the service recipient rights and an explanation of those rights. You must maintain documentation of P1’s receipt of a copy and an explanation of the rights. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P1), 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 provide services in response to P1’s needs, interests, and preferences when the license holder stated that the assessment of the scope of services the license holder documented in P1’s support plan addendum did not apply to P1 and was developed for another person. b. The license holder failed to implement P1’s preferences in P1’s service planning when the license holder failed to address P1 by P1’s preferred pronouns throughout P1’s support plan addendum. Corrective Action Ordered: Within 60 days of receiving this order, you must review and revise P1’s support plan addendum to meet the requirements of this subdivision. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for basic support services as required. The license holder failed to complete the following after initiating P1’s individualized home supports with training services on May 4, 2021, and P1’s 24 hour emergency assistance services on July 11, 2023: · complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation for each service initiation. The license holder completed the preliminary support plan addendum for P1’s individualized home supports with training on June 10, 2021; and · review and revise as needed the preliminary support plan addendum within 60 calendar days of service initiation to document the services that will be provided including: o how, when, and by whom services will be provided; and o the person responsible for overseeing the delivery and coordination of services for each service initiated. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete a preliminary support plan addendum based on the support plan for P1’s 24 hour emergency assistance service. The support plan addendum must include how, when, and by whom services will be provided; and · review and revise P1’s current support plan addendum to include the information identified above for the individualized home supports with training service. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. 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. Minnesota Administrative Rules, chapter 9544.0020, subpart 41 defines “positive support strategy” to mean a strengths-based strategy based on an individualized assessment that emphasizes teaching a person productive and self-determined skills or alternative strategies and behaviors without the use of restrictive interventions. The license holder failed to evaluate with P1 whether identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months. Corrective Action Ordered: Within 60 days of receiving this order, you must: · evaluate P1’s positive support strategies; · based upon the results of the evaluation, determine whether changes are needed in the positive support strategies used for P1, and, if so, make appropriate changes; and · maintain documentation of the above mentioned evaluation in P1’s service recipient record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not maintain a service recipient record as required. The license holder failed to maintain progress or daily log notes recorded by the program in P1’s service recipient record for each service the license holder provided. Corrective Action Ordered: Immediately, you must begin maintaining progress or daily log notes in P1’s service recipient record for each service you provide. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.10, subdivision 4 and Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. a. The license holder failed to inform P1 and P1’s case manager of the following policies and procedures affecting a person’s rights under section 245D.04 within five working days of initiating P1’s individualized home supports with training on May 4, 2021: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. The license holder informed P1 of the above mentioned policies and procedures on May 6, 2022. b. The license holder failed to inform P1 and P1’s case manager of the following policies and procedures affecting a person’s rights under section 245D.04 within five working days of initiating P1’s 24 hour emergency assistance service on April 10, 2023: · grievance policy and procedure; · service suspension and termination policy and procedure; · data privacy; and · emergency use of manual restraints policy and procedure. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide the policies and procedures identified in letter (b) to P1, and P1’s case manager; and · obtain written acknowledgement from P1 indicating they have been informed of the program’s emergency use of manual restraint policy and procedure. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of one staff person whose record was reviewed (SP1), the license holder did not provide orientation training as required. The license holder failed to provide SP1 with training on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP1 with training on strategies to minimize the risk of sexual violence. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training as required. 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 failed to provide SP1 with annual training on the following topics: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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; · 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 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; · 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. Corrective Action Ordered: Within 60 days of receiving this order, you must complete the above mentioned training for SP1 and maintain documentation of the trainings in SP1’s personnel record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinator (SP1), provided coordination of service delivery and evaluation for each person served by the program. See citations 1 through 10 for the designated coordinator’s failure to provide supervision, support, and evaluation of 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. a. The license holder failed to ensure that the designated manager (SP1) provided program management and oversight of the services provided by the license holder. See citations 1 through 10 for the designated manager’s 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. Corrective Action Ordered: Within 20 days of receiving this order, you must: · designate a staff person, other than SP1, who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP1, to provide program management and oversight of the services provided by the license holder; and · submit the name(s) and qualifications of the staff person(s) who will act as the designated coordinator and designated manger to your licensor for approval. The same person may perform both functions if the work and education requirements are met in section 245D.081, subdivisions 2 and 3. Compliance with this subdivision will be monitored onsite. 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 lacey.l.walsvik@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: Lacey Walsvik 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 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. Lacey Walsvik, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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