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June 25, 2025 Jay Freshour, Authorized Agent Genesis Group Homes Inc 8245 93rd Avenue North Brooklyn Park, MN 55445-1509 License Number: 1072844 (245D – HCBS) CORRECTION ORDER Dear Jay Freshour: On April 29-May 1, 2025, a licensing review of Genesis Group Homes Inc, located at 8245 93rd Avenue North, Brooklyn Park, 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.04, subdivision 1. Violation: For one of ten persons whose record was reviewed (P6), the license holder did not provide service recipient rights as required. The license holder failed to provide P6, or their legal representative, with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation as required. Corrective Action Ordered: Immediately upon receiving this order, you must: · provide P6 with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights; and · maintain documentation of P6’s receipt of a copy and an explanation of the rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For two persons whose records were reviewed (P1, P2), the license holder did not document and implement the restriction of a person’s rights as required. a. The license holder initiated a restriction of rights in P1’s support plan addendum dated October 24, 2023, that restricted P1’s right to access the kitchen. The license holder failed to: · document applicable and objective measures set as conditions for ending the restriction; and · review the need for the restriction based on the conditions for ending the restriction semiannually from the date of initial approval, at minimum, as required. b. The license holder documented in P2’s support plan addendum, dated October 23, 2024, that P2 “may have unsupervised time with friends at his/her apartment as long as staff get a copy of his/her friends’ IDs first. He/She may have visitors spend the night at his/her apartment if prior approval is obtained by the guardian, and staff must get a copy of the visitor’s ID.” The right to choose the person’s visitors and time of visits and have privacy for visits is a right afforded to persons residing in a residential site or where the license holder is the owner, lessor, or tenant of the residential site. The license holder failed to preserve P2’s protection-related rights and document the restriction of rights for P2 as required. Corrective Action Ordered: Within 30 days of receiving this order, you must: · discuss with P1’s team to determine the objective measures set as conditions for ending the restriction for P1; and · review the need for the restriction for P1 based on the conditions for ending the restriction semiannually from the date of initial approval, at minimum, or more frequently if requested by P1, P1’s legal representative, and case manager; · discuss with P2’s team whether a restriction of P2’s rights is necessary to ensure the health, safety, and well-being of the person; · determine the least restrictive alternative manner necessary to protect P2 and provide support to reduce or eliminate the need for each restriction in the most integrated setting and inclusive manner; · determine the justification for each restriction based on an assessment of P2’s vulnerability related to exercising the right without restriction; · determine the objective measures set as conditions for ending each restriction for P2; and · review the need for each restriction based on the conditions for ending the restriction semiannually from the date of initial approval, at minimum, or more frequently if requested by P2, P2’s legal representative, and case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P10), the license holder did not meet health service needs as required.
The license holder was assigned responsibility for administering P10’s medications. The license holder failed to maintain documentation of how P10’s health needs would be met, including a description of the procedures the license holder would follow to provide medication administration. The license holder maintained two protocols with identical administration instructions for two of P10’s prescribed pro re nata (PRN) medications. Due to the identical instructions, the license holder was unable to demonstrate the correct procedure for the administration of the two medications. Corrective Action Ordered: P10 is no longer receiving services, therefore no corrective action is needed for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.06, subdivision 8. Violation: For one person whose record was reviewed (P10), the license holder did not review the positive support transition plan (PSTP) as required. The license holder developed a PSTP for P10 dated February 13, 2022, on the forms prescribed by the commissioner. The form prescribed by the commissioner requires that the expanded support team reviews the effectiveness of the PSTP no less than every quarter (or 90 days). The license holder failed to complete these reviews. Corrective Action Ordered: P10 is no longer receiving services and therefore there is no corrective action for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.061, subdivision 6, paragraph (a). Violation: For one person whose record was reviewed (P10), the license holder did not complete and document an internal review of each report of emergency use of manual restraint (EUMR) as required. The license holder failed to thoroughly evaluate the need for changes to be made to P10’s support plan as evidenced by 21 internal reviews between April 2022 and February 2023, that all indicated that no changes were needed. Corrective Action Ordered: P10 is no longer receiving services and therefore there is no corrective action for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P10), the license holder did not provide services as assigned in the support plan as required. The license holder failed to complete bi-weekly team meetings for P10 as indicated in his/her support plan addendum. Corrective Action Ordered: P10 is no longer receiving services, therefore no corrective action is needed for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P3), the license holder did not provide person-centered planning and service delivery as required. The license holder failed to provide P3 with person-centered planning and delivery that identified and supported what was important to P3 as well as what was important for P3. The name of another person served was frequently used in P3’s support plan addendum; therefore, it was unable to be determined if P3's support plan addendum documented P3's or another vulnerable adult's needs, interests, and preferences. Additionally, the license holder failed to provide services in a manner that supported P3's accomplishment of personal goals and service outcomes P3 desired. The license holder developed an outcome for P3 that was to reduce behavioral incidents; however, P3 had no documented history of several of these behaviors. Corrective Action Ordered: Within 30 days of receiving this order you must update P3’s plan to include only P3’s name, needs, interests, and preferences. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P10), the license holder did not complete assessments for intensive service planning as required. The license holder failed to include a summary of a discussion of how technology might be used to meet P10’s desired outcomes in P10’s support plan addendum. Corrective Action Ordered: P10 is no longer receiving services therefore no corrective action is needed for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). 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. The license holder failed to include the following required documentation: · the methods or actions that will 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; o any equipment and materials required; o techniques that are consistent with P1’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: P1 is no longer receiving a service which requires outcomes, therefore no correction for P1 is needed. You must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P6), the license holder did not inform and provide written or electronic copies of policies and procedures as required. The license holder failed to inform and provide copies to P6 and P6’s case manager of the following policies and procedures that affect a person’s rights within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Corrective Action Ordered: Immediately, you must inform and provide copies of the above-mentioned policies and procedures to P6 and P6’s case manager. Additionally, you must obtain a written acknowledgement from P6 that P6 was notified of your policy on the emergency use of manual restraint. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a), clause (4). Violation: For one person whose record was reviewed (P6), the license holder did not provide orientation to the internal and external reporting procedures and program abuse prevention plan (PAPP) as required. The license holder failed to provide an orientation to the internal and external reporting procedures and PAPP to P6 within 24 hours of admission. Corrective Action Ordered: Immediately, you must provide an orientation to the internal and external reporting procedures and PAPP to P6. You must maintain documentation with the date P6 received this orientation in P6’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For four persons whose records were reviewed (P3, P4, P6, P10), the license holder did not establish and enforce individual abuse prevention plans as required. a. The license holder failed to develop an IAPP for P3 that included the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services. b. The license holder failed to develop an IAPP for P4 that included the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services. c. The license holder failed to develop an individual abuse prevention plan (IAPP) for P6 as part of the initial individual program plan or service plan when services were initiated with P6 on May 24, 2024. The license holder developed the IAPP on July 28, 2024. d. The license holder failed to develop an IAPP for P10 that included the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P3 to include the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services; · develop an IAPP for P4 to include the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services; and · P10 is no longer receiving services, therefore no corrective action is needed for P10. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For four persons whose records were reviewed (P5, P6, P7, P9), the license holder did not maintain positive support strategies as required. a. For P5 and P6, the license holder failed to incorporate positive support strategies and implement the positive support strategies in writing into an existing support plan. b. For P7 and P9, the license holder failed to evaluate positive support strategies every six months as required. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate the identified positive supports strategies with P5 and P6; · develop and implement positive support strategies in writing for P5 and P6; and · review the positive support strategies with P5, P6, P7, and P9 every six months. On an ongoing basis, you must maintain compliance as required in this subpart. 14. Citation: Minnesota Rules, part 9544.0110. Violation: For one person whose record was reviewed (P6), the license holder did not meet the requirements for reporting use of restrictive interventions and incidents as required. P6 was involved in a behavioral incident that resulted in a call to 911 in June 2024. The license holder failed to use the behavior intervention report form to report this incident to the commissioner. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this part. 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. Dylan Sobota, HCBS Licensor Licensing Division Office of Inspector General 651-431-2690
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