Minnesota

August 1, 2025

Fardosa Ahmad, Authorized Agent

Heavenly Home Care LLC

1821 University Avenue West Suite 351

Saint Paul, Minnesota 55104-2801

License Number: 1106119 (245D – HCBS)

CORRECTION ORDER

Dear Fardosa Ahmad:

On July 7, 2025, a licensing review of Heavenly Home Care LLC, located at 1821 University Avenue West, Saint Paul, 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 two of three persons whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required.

a. The license holder provided multiple services to P1. The license holder did not develop an IAPP for P1 that included a statement of specific measures that would be taken to minimize the risk of abuse to P1 within the scope of each licensed service P1 received.

b. The license holder assessed P1 to be vulnerable to self-abuse in P1’s IAPP, specifically P1’s inability to care for self-help needs. P1’s support plan also documented that P1 was susceptible to self-neglect including refusal to eat, lack of preservation skills, and neglected to self-administer medications. The license holder did not develop an IAPP for P1 that accurately assessed all areas of P1’s susceptibility to self-abuse.

c. The license holder assessed P2 to be vulnerable to self-abuse in P2’s IAPP. The license holder did not develop an IAPP for P2 that included a statement of specific measures that would be taken to minimize the risk of abuse to P2. Additionally, the license holder did not review P2’s IAPP annually. The license holder reviewed P2’s IAPP in February 2023 and March 2024.

Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise P1’s and P2’s IAPP to include a statement of measures that will be taken to minimize the risk of abuse to P1 and P2 within the scope of each licensed service P1 and P2 receives. Additionally, you must provide orientation on the updates to P1’s and P2’s IAPP to all staff that provide direct support to P1 and P2. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For one person whose record was reviewed (P2), the license holder did not provide each person with a written notice that identified the service recipient rights 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 P2 with a written notice that identified the service recipient rights, and an explanation of those rights annually. The license holder provided P2 with the required written notice in February 2023 and March 2024.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.07, subdivision 2.

Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning for basic support services as required.

The license holder did not review and revise P1’s, P2’s, and P3’s preliminary support plan addendum within 60 calendar days of service initiation to document the services that would be provided including, how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. The license holder initiated services for P2 on January 23, 2023, and reviewed P2’s preliminary support plan addendum in March 2024.

Corrective Action Ordered: Within 30 days of receiving this order, you must complete support plan addendums for P1 and P3 that document the services that will be provided including how, when, and by whom the services will be provided. Additionally, you must provide orientation to the updates to P1’s and P3’s support plan addendum to all staff that provide direct support to P1 and P3. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.071, subdivision 3.

Violation: For one person whose record was reviewed (P3), the license holder did not conduct an initial service planning meeting as required.

The license holder did not:

· complete assessments in the following areas before the 45-day planning meeting:

o P3's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments;

o P3's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and

o P3's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others;

· meet with P3, P3's legal representative, the case manager, and other members of the support team or expanded support team within 45 days of service initiation to determine:

o the scope of the services to be provided to support the person's daily needs and activities;

o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

o the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule;

o whether the current service setting is the most integrated setting available and appropriate for the person;

o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and

o how technology might be used to meet the person's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include:

§ a statement regarding any decision that is made regarding the use of technology; and

§ a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· complete the assessments for P3 including the requirements stated above. Assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms.

· meet with P3, their legal representative, the case manager, and other members of the support team or expanded support team to determine the information listed above.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.071, subdivision 4.

Violation: For one person whose record was reviewed (P3), the license holder did not develop service outcomes and supports as required.

The license holder did not document the following supports and methods to be implemented to support P3 and accomplish outcomes:

· the methods or actions that would 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 were provided;

o any equipment or materials required; and

o techniques that were consistent whit the person’s communication mode and learning style;

· the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected;

· the projected starting date for implementing the supports and methods;

· the date by which progress towards accomplishing the outcome would be reviewed and evaluated; and

· the names of the staff person or position responsible for implementing the supports and methods.

Corrective Action Ordered: Within 30 days of receipt of this order, you must develop the information listed above in P3’s support plan addendum. Additionally, you must provide orientation to the updates to P3’s supports and methods to all staff that provide intensive service direct support to P3. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide policies and procedures as required.

The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights to P1’s, P2’s, and P3’s case manager within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure; and

· emergency use of manual restraints policy and procedure.

The license holder provided the above mentioned policies and procedures to P1’s case manager on May 21, 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the policies and procedures affecting a person’s rights to P2’s and P3’s case manager. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Rules, chapter 9544.0030, subpart 1.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate the identified positive support strategies with P1 and P3 at least every six months.

Corrective Action Ordered: Immediately, you must incorporate positive support strategies into P1’s and P3’s existing support plan addendum. Additionally, the positive support strategies must be evaluated at least every six months with P1 and P3 to determine whether changes are needed, and if so, make appropriate changes. You must provide orientation on the updates to P1’s and P3’s support plan addendum to all staff that provide direct support to P1 and P3. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subpart.

8. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not maintain service recipient records as required.

The license holder did not maintain progress or daily log notes for P1, P2, and P3 that were recorded by the program.

Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for all service recipients. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation as required.

a. The license holder did not provide and ensure completion of orientation to SP1 within 60 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 Minnesota Statutes, section 245D.06, subdivision 1; and

o following safety practices established by the license holder as required in section 245D.06, subdivision 2;

· the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· data privacy requirements according to Minnesota Statutes, section 13.01 to 13.10 and 13.24, 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 Minnesota Statutes, section 245D.04;

· sections 245A.65 and 6266.557 governing maltreatment reporting for and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment;

· the principles of person-centered 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 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; and

· staff responsibilities related to 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.

b. SP2’s hire date was January 31, 2023. The license holder did not provide and ensure completion of orientation to SP2 within 60 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 Minnesota Statutes, section 245D.06, subdivision 1; and

o following safety practices established by the license holder as required in section 245D.06, subdivision 2;

· 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 provided SP2 training on this topic in January 2025;

Corrective Action Ordered: Within 30 days of receipt this order you must provide SP1 and SP2 the training detailed above. Additionally, you must document this training in SP1’s and SP2’s personnel record according to Minnesota Statutes, section 245D.095, subdivision 5. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required.

The license holder did not provide the following orientation to SP1 and SP2 before having unsupervised direct contact with a person served by the program:

· the person’s support plan or support plan addendum as it related 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.

11. 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.

a. The license holder did not provide annual training on the following topics to SP1 in 2024:

· data privacy requirements according to Minnesota Statutes, 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 Minnesota Statutes, section 245D.04;

· sections 245A.65 and 626.557, governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment, including annual review to VA maltreatment reporting;

· 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 service provide by the staff person;

· staff responsibilities related to 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;

· 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.

b. The license holder did not provide annual training on the following topics to SP2 in 2024:

· basic first aid. The license holder provided SP2 this training in February 2023 and January 2025; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder provided SP2 this training in February 2023 and January 2025.

12. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required.

The license holder failed to maintain a personnel record for SP1 and SP2 that included documentation of training, including the number of hours per subject area and the name of the trainer or instructor.

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

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

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/