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July 8, 2025 Fatou Jallow, Authorized Agent Empathy Home Care, Inc. 4600 Oak Grove Parkway North Brooklyn Park, Minnesota 55443-4062 License Number: 1119230 (245D – HCBS) CORRECTION ORDER Dear Fatou Jallow: On June 8, 2025, a licensing review of Empathy Home Care, Inc., located at 4600 Oak Grove Parkway 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 245A.65, subdivision 1, paragraph (c). Violation: For one of six persons whose records were reviewed (P4), the license holder did not provide orientation to the policies and procedures related to suspected or alleged maltreatment as required. The license holder did not provide P4 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder initiated P4’s services on June 28, 2024, and provided the orientation on July 26, 2024. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder did not to conduct an accurate individualized assessment of P3’s susceptibility to abuse. The IAPP the license holder developed for P3 indicated a history of opioid use and a relapse resulting in hospitalization and an in-patient treatment program. The license holder stated that this information was inaccurate for P3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P3’s IAPP to include an individualized assessment of P3’s susceptibility to abuse; and · you must include a statement of the specific measures that would be taken to minimize the risk of abuse for each assessed area of risk of abuse. 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 (P3), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was assigned the responsibility of meeting P3’s health service needs. The license holder did not maintain documentation on how P3’s health needs would be met including a description of the procedures the license holder would follow in order to: · monitor health conditions according to written instructions from a licensed health professional; and · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above mentioned information for P3. 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 (P3), the license holder did not implement medication administration procedures as required. The license holder was assigned responsibility for medication administration in P3’s support plan addendum. The license holder did not implement medication administration procedures to ensure P3 took medications and treatment as prescribed when P3’s medication administration record (MAR) indicated that P3 missed their medications on 15 instances from April 28, 2025, to June 3, 2025. Additionally, the license holder did not document a notation of when a medication was administered to P3 in 30 instances from April 28, 2025, to June 3, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must begin implementing medication administration procedures to ensure P3’s medications are administered as prescribed. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For one person whose record was reviewed (P6), the license holder did not review, and report medication administration issues as required. a. In a Correction Order dated December 4, 2024, the license holder was ordered to complete MAR reviews for P6 from January 2024 to current (December 2024) to identify medication errors. Based on the MAR review, the license holder was also ordered to report all occurrences of P6’s refusals to take medications as prescribed to P6’s case manager. The license holder did not complete the corrective action ordered for P6. b. The license holder did not complete MAR reviews for P6 that identified the specific medication errors that occurred. The license holder also did not develop and implement a plan to correct patterns of medication administration errors when identified for P6. Additionally, the license holder did not report medication errors, including medication refusals to P6’s case manager as they occurred. From February 2025-May 2025, P6 did not receive medications on multiple occasions each month and the license holder did not report the medication errors to P6’s case manager as they occurred. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct a review of P6’s MARs from January 2025 - June 2025 to ensure the information maintained in the MAR is current and to identify medication errors, including medication refusals. You must maintain documentation of the MAR review in P6’s record; · based on the review of P6’s MARs, report all occurrences of P6’s refusal or failure to take medications as prescribed to P6’s case manager. You must maintain documentation of these reports in P6’s record; · submit the MAR review you completed for P6 to your licensor; and · develop and submit a plan to your licensor detailing how you will come into compliance with medication administration reviewing and reporting requirements and maintain ongoing compliance throughout your program.
6. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For two persons whose records were reviewed (P3 and P6), the license holder did not meet the requirements for psychotropic medication use and monitoring. The license holder was assigned the responsibility for administering medications to P3 and P6. P3 and P6 were prescribed psychotropic medications. The license holder did not document the target symptoms each psychotropic medication was used to alleviate for the person. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must document the information above in P3’s, and P6’s support plan addendums. You must submit evidence that this was documented in P3’s and P6’s support plan addendums to your licensor. On an ongoing basis, you maintain compliance as required. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P1, P3, and P4), the license holder did not meet service planning requirements for intensive support services. The license holder did not have a discussion of how technology might be used to meet P1’s, P3’s and P4’s desired outcomes at their initial planning meetings. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · have a discussion with P1 and members of P1’s support team, P3 and members of P3’s support team, and P4 and members of P4’s support team regarding how technology may be used to meet the person’s desired outcomes; · document a summary of this discussion in P1’s, P3’s and P4’s support plan addendums that includes: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made; and · submit the summaries of the discussions held for P1, P3, and P4 to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not develop service outcomes and support as required in this subdivision. a. The license holder did not develop a service plan for P4 that documented the supports and methods to be implemented to support the person and accomplish outcomes within ten working days of the initial planning meeting. The license holder held P4’s initial planning meeting on September 2, 2024, and documented P4’s supports and methods on April 4, 2025. b. The license holder did not develop a service plan for P5 that documented the measurable and observable criteria for identifying when the desired outcome has been achieved for P1’s outcome documented as “Outcome #1” in P1’s support plan addendum. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan for P5 that includes the service outcomes and supports listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P6), the license holder did not complete service plan review as required. The license holder was required to provide written reports that summarized P6’s person's status and progress toward achieving the identified outcomes to P6’s support team on a quarterly basis. The license holder did not provide quarterly written reports to P6’s support team. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P4 and P6), the license holder did not provide policies and procedures as required. a. The license holder did not inform and provide P6’s case manager with copies 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. b. The license holder did not inform and provide copies of the following policies and procedures that affect affecting a persons’ rights to P4 and P4’s case manager within five days of service initiation. The license holder initiated P4’s services on June 28, 2024, and provided the policies to P4 and P4’s case manager on July 26, 2024. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P6’s case manager the policies mentioned above. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P4), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required. The license holder did not obtain a written acknowledgement from P4 at the time of service initiation indicating that P4 had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, section 245D.04. The license holder initiated P4’s services on June 28, 2024, and obtained the written acknowledgement from P4 on July 26, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rules, 9544.0110. Violation: For one person whose record was reviewed (P6), the license holder did not report the incidents as required.
P6 was involved in behavioral incidents on April 8, 2025, April 11, 2025, and April 23, 2025, that resulted in calls to 911. The license holder did not use the behavior intervention report form (BIRF) required by the commissioner to report these incidents to DHS. Repeat Violation: In a Correction Order that DHS issued on December 4, 2024, you were previously found in violation of this same rule. Corrective Action Ordered: Within 15 days of receipt of this order, you must report the above mentioned incidents using the BIRF form required by the commissioner. Within 30 days of receiving this order, you must: o submit evidence to your licensor that the BIRFs for the incidents for P6 mentioned above; o develop and submit a plan to your licensor detailing how you will come into compliance with these reporting requirements and maintain ongoing compliance throughout your program. On an ongoing basis, you must maintain compliance as required in this subpart. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of four staff persons whose records were reviewed (SP1), the license holder did not provide orientation training as required. The license holder did not provide SP1 with the following orientation training within 60 calendar days of hire: · the license holder's current policies and procedures, including their location and access, and staff responsibilities related to implementation of those policies and procedures, including: o grievances; o service suspension; o service termination; o prohibition of drug and alcohol use; o emergency use of manual restraint; o health service coordination and care; o safe transportation; and o service admission; · the safe and correct use of manual restraint on an emergency basis and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the SP1 with training on the topics listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not ensure SP1 received instruction on the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and the person's individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure SP1 has reviewed and received instruction on the requirements identified above for each service recipient they are providing direct support services to. Additionally, you must maintain documentation of this training in SP1’s personnel record as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose records were reviewed (SP4), 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. The license holder did not provide SP4 annual training on the following topics in 2025: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. The license holder most recently provided this to SP4 in March 2024; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services provided by the staff person. The license holder provided this training to SP4 in March 2024, and April 2025; • the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. The license holder most recently provided this training to SP4 in March 2024; • staff responsibilities related to the prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. The license holder most recently provided this training to SP4 in March 2024; · basic first aid. The license holder provided this training to SP4 in March 2024, and April 2025; and · strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities. The license holder most recently provided this training to SP4 in March 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP4 with training on the above mentioned topics. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 24D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP4), the license holder did not maintain personnel records as required.
a. The license holder did not maintain documentation in SP1’s personnel record sufficient to determine SP1’s date of hire. b. The license holder did not document SP4’s annual review of the license holder’s program abuse prevention plan (PAPP) in 2024 and 2025, including the date the training was completed, the number of hours per subject area and the name of the trainer or instructor in SP4’s personnel record. Corrective Action Ordered: On an ongoing basis, you must maintain the following training information in each staff person’s personnel record as required in this subdivision: · the date the training was completed; · the number of hours per subject area; and the name of the trainer or instructor. 17. Citation: Minnesota Statutes, section 245D.081, subdivision 3, paragraph (a). Violation: The license holder did not provide program oversight and management as required. The license holder did not ensure the designated manager provided program management and oversight of the services provided by the license holder that included the following when the license holder did not complete corrective action ordered according to a Correction Order issued December 4, 2024: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e); · ensuring 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); and · ensuring corrective action is taken when ordered by the commissioner. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at michael.byrne@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: Michael Byrne 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. Michael Byrne, Human Services Licensor Licensing Division Office of Inspector General 651-431-6709
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