Minnesota

August 6, 2025

James Lanigan, Authorized Agent

Opal Services Inc

1335 Corporate Center Curve #100

Eagan, Minnesota 55121-1398

License Number: 1069678 (245D – HCBS)

License Number: 1069679 (Community Residential Services)

1069683 (Community Residential Services)

1069692 (Community Residential Services)

1069695 (Community Residential Services)

CORRECTION ORDER

Dear James Lanigan:

On June 16 and June 17, 2025, a licensing review of Opal Services Inc, located at 1335 Corporate Center Curve, Eagan, 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 and 2.

Violation: For two of five persons whose records were reviewed (P2 and P4), the license holder did not provide orientation to internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required.

a. The license holder did not provide orientation to the internal and external reporting procedures for alleged or suspected maltreatment to P2 within 24 hours of admission. Additionally, the license holder did not provide P2 with orientation to the program abuse prevention plan (PAPP), within 24 hours of admission. The license holder initiated services with P2 on October 16, 2024, and these orientations were provided in June 2025.

b. The license holder did not provide orientation to the internal and external reporting procedures for alleged or suspected maltreatment and the program abuse prevention plan to P4 within 24 hours of admission. The license holder initiated services with P4 on June 29, 2023, and this orientation was provided on July 14, 2023.

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

· conduct an audit of all service recipient records to ensure orientation to the internal and external reporting procedures for alleged or suspected maltreatment and the site-specific program abuse prevention plan has been provided;

· for any individuals served and legal representatives identified in the audit to not have received orientation to these procedures, an orientation must be provided, and documentation of this orientation must be maintained in the service recipient record as required; and

· the results of this audit must be maintained in the program records for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 2.

Violation: For five persons whose records were reviewed (P1-P5), the license holder did not develop and review an individual abuse prevention plan (IAPP) 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 assessed P1 as susceptible to sexual abuse. The license holder did not include in the IAPP, the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services to P1 and other vulnerable adults.

b. The license holder assessed P2 as susceptible to abuse in multiple areas. The license holder did not include in the IAPP, the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services to P2 and other vulnerable adults.

c. The license holder did not review P3’s IAPP with the interdisciplinary team annually in 2025. P3’s IAPP was last reviewed in March 2024.

d. The license holder assessed P4 as susceptible to abuse in multiple areas. The license holder did not include in the IAPP, the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services to P4 and other vulnerable adults.

e. The license holder did not review P5’s IAPP with the interdisciplinary team annually in 2024. P5’s IAPP was last reviewed in June 2023.

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

· revise P1’s IAPP to include the information in letter (a), review the updated IAPP with P1, P1’s legal representative and P1’s case manager, and maintain documentation of this review in the service recipient record as required;

· revise P2’s IAPP to include the specific actions you will take to minimize the risk of abuse in every area of vulnerability identified for P2, review the updated IAPP with P2, P2’s legal representative and P2’s case manager, and document this review in the service recipient record as required;

· review P3’s and P5’s IAPP with their interdisciplinary team members and make the necessary revisions;

· revise P4’s IAPP to include the specific actions you will take to minimize the risk of abuse in every area of vulnerability identified for P4, review the updated IAPP with P4, P4’s legal representative and P4’s case manager, and document this review in the service recipient record as required; and

· provide staff orientation to the updated IAPP’s for P1-P5 and maintain documentation of this orientation in the personnel record as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not provide 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.

a. The license holder did not provide P1 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. The last copy the license holder provided to P1 was on May 2, 2024. In addition, in the written notice that was provided to P1 on May 2, 2024, the license holder did not include the following rights:

· have access to the person’s personal possessions at any time, including financial resources;

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· have freedom and support to access food and potable water at any time;

· have the freedom to furnish and decorate the person’s bedroom or living unit;

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects;

· a setting that is free from hazards that threaten the person’s health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

b. The license holder did not provide P2 or P2’s 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. The license holder initiated services with P2 on October 16, 2024 and the written notice was provided in June 2025. In addition, the written notice provided to P2 in June 2025 did not include the following rights:

· have access to the person’s personal possessions at any time, including financial resources;

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· have freedom and support to access food and potable water at any time;

· have the freedom to furnish and decorate the person’s bedroom or living unit;

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects;

· a setting that is free from hazards that threaten the person’s health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

c. The license holder did not provide P4 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. The license holder initiated services with P4 on June 29, 2023, and the rights were provided on July 14, 2023. In addition, the written notice provided to P4 on July 14, 2023 did not include the following rights:

· have access to the person’s personal possessions at any time, including financial resources;

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· have freedom and support to access food and potable water at any time;

· have the freedom to furnish and decorate the person’s bedroom or living unit;

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects;

· a setting that is free from hazards that threaten the person’s health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

Additionally, the license holder did not provide P4 or P4’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights annually in 2023 and 2024.

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

· ensure the written notice of service recipient rights you are providing to service recipients and legal representatives includes all the rights identified in 245D.04, subdivisions 2 and 3;

· provide P1, P2, and P4 with a written notice that identifies the service recipient rights in 245D.04 subdivisions 2 and 3, and an explanation of those rights;

· conduct an audit of all service recipient records to ensure service recipients have received a written notice of the service recipient rights and an explanation of those rights at service initiation and annually as required;

· for any individuals identified in the audit not to have received a copy of the service recipient rights, you must provide a written notice of the service recipient rights and an explanation of those rights;

· documentation of these individuals receiving a copy of the service recipient rights must be maintained in the service recipient record as required; and

· maintain the results of the audit and corrective action taken in your program files for DHS licensors to review.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

4. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b).

Violation: For one of five persons whose records were reviewed (P5), the license holder did not ensure the exercise and protection of P5’s rights.

The license holder did not provide a setting that was clean and free from accumulation of dirt and grease.

Corrective Action Ordered: Within 30 days of receiving this order, you must clean all areas of the home to ensure compliance with this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 2

Violation: For five persons whose records were reviewed (P1-P5), the license holder did not document health service needs as required.

a. The license holder was assigned the responsibility for administering P1’s medications. The license holder did not document the following information in P1’s medication administration record (MAR):

· information of risks and other side effects that are reasonable to expect and any contraindications to its use;

· the possible consequences if the medication or treatment is not taken or administered as directed;

· instructions on when and to whom to report the following:

o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or refusal by the person; and

o the occurrences of possible adverse reaction to the medication or treatment.

b. The license holder did not obtain written authorization from P2’s legal representative before administering medication to P2. The license holder initiated services for P2 on October 16, 2024, and the written authorization to administer P2s medications was obtained June 17, 2025. The license holder administered medications to P2 January 2025 through May 2025 with no written authorization from the legal representative to do so.

c. The license holder was assigned the responsibility for administering P3’s medications. The license holder did not document the following information in P3’s medication administration record (MAR):

· information of risks and other side effects that are reasonable to expect and any contraindications to its use;

· the possible consequences if the medication or treatment is not taken or administered as directed;

· instructions on when and to whom to report the following:

o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or refusal by the person; and

o the occurrences of possible adverse reaction to the medication or treatment.

d. The license holder did not obtain written authorization from P4’s legal representative to administer medication or treatment.

e. The license holder did not ensure the following information was documented in P4’s medication administration record:

· information on any risks or other side effects that are reasonable to expect, and any contraindications to its use;

· the possible consequences if the medication or treatment is not taken or administered as directed;

· instruction on when and to whom to report medication errors;

· notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made; and

· notation of when a medication or treatment is started, administered, changed, or discontinued.

f. The license holder was assigned the responsibility for administering P5’s medications. The license holder did not document the following information in P5’s medication administration record (MAR):

· information of risks and other side effects that are reasonable to expect and any contraindications to its use;

· the possible consequences if the medication or treatment is not taken or administered as directed;

· instructions on when and to whom to report the following:

o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or refusal by the person; and

o the occurrences of possible adverse reaction to the medication or treatment.

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

· obtain written authorization from P4’s legal representative to administer medication or treatment;

· include in P1’s medication administration record the information listed above in (a);

· include in P3’s medication administration record the information listed above in (c);

· include in P4’s medication administration record the information listed above in (d);

· include in P5’s medication administration record the information listed above in (f);

· conduct an audit of all service recipient records to ensure authorization to administer medication or treatment has been obtained from persons served or legal representatives;

· for any service recipients identified to not have an authorization to administer medication or treatment on file, you must obtain a written authorization from the person served or legal representative to administer medication or treatment;

· conduct an audit of medication administration records to ensure the requirements outlined in 245D.05, subdivision 2, paragraph (c) are included; and

· maintain documentation of the audit and corrective action taken in the program records for DHS licensors to review.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

6. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), clause 6.

Violation: For four persons whose record was reviewed (P1, P2, P4, and P5), the license holder did not document medication administration as required.

a. The license holder was responsible for administering P1’s medications. DHS Licensors reviewed P1’s MARs from January 1, 2025, to June 15, 2025. The license holder insufficiently documented notations of when a medication was administered in over 400 instances from January 1, 2025, to June 15, 2025.

b. The license holder was responsible for administering P2’s medications. DHS licensors reviewed P2’s MARs from January 1, 2025, to May 30, 2025. The license holder insufficiently documented notations of when a medication was administered in over 150 instances from January 1, 2025, to May 30, 2025.

c. The license holder was responsible for administering P4’s medications. DHS licensors reviewed P4’s MARs from August 1, 2023, through May 31, 2025. The license holder inaccurately documented medication administration for P4 when:

· there was no notation of when a medication administered for 18 days in the time period of August 1, 2023, through May 31, 2025.

· medication administration was documented for thirty days in February 2024;

· there was only one medication on the MAR for January 2025 which was inconsistent from the month prior and the month after; and

· there was no MAR for March 2025 in the client record and there was an incomplete MAR maintained in the file for May 2025.

d. The license holder was responsible for administering P5’s medications. At the time of the review, a medication administration record was not available to document medication administration for P5 for June 2025. DHS licensors were, therefore, unable to determine if medications had been administered to P5 during the month of June 2025.

Corrective Action Ordered: The license holder made a medication administration record available for P5 once the error was discovered, therefore no further corrective action for the information listed above in (d) is required. On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

7. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For five persons whose records were reviewed (P1-P5), the license holder did not review the MARs as required.

The license holder did not review P1’s-P5’s MAR every three months to ensure the records were current and to identify medication administration errors.

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

· review P1’s, P2’s, P3’s, P4’s and P5’s MARs for the past six months to ensure that all the information in the MAR is current and to identify medication errors including medication administration documentation errors. The review must be documented in the service recipient record as required;

· based upon the results of the review, you must develop, document, and implement a plan to correct the patterns of medication administration errors identified. Documentation of this review and the plan for correction must be maintained in the medication administration record as required;

· based upon the results of the review, you must report the following to the person’s legal representative, if applicable, and case manager:

o any reports required in Minnesota Statutes, section 245D.05, subdivision 2 paragraph (c), clause (4);

o a person’s refusal or failure to take or receive medication or treatment as prescribed; and

· you must develop and implement a plan for MAR reviews to be regularly conducted as required. This plan must be maintained in your program files for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

8. Citation: Minnesota Statutes, section 245D.051, subdivision 1.

Violation: For five persons whose records were reviewed (P1- P5), the license holder did not maintain documentation for psychotropic medications as required.

Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b), clause (2) defines “target symptom” to mean any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation.

a. The license holder did not document a description of the target symptoms that P1’s psychotropic medications were to alleviate.

b. The license holder did not document a description of the target symptoms that P2’s psychotropic medications were to alleviate.

c. The license holder did not collect and report on medication and symptom-related data as instructed by the prescriber for P3.

d. The license holder did not document a description of the target symptoms that P4’s psychotropic medications were to alleviate and how the license holder would monitor and measure changes of the target symptoms to be alleviated by the medication. Additionally, the license holder did not collect and report monitoring data as required by P4’s medication prescriber.

e. The license holder did not collect and report on medication and symptom-related data as instructed by the prescriber for P5.

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

· document a description of the target symptoms P1’s psychotropic medications are prescribed to alleviate;

· document a description of the target symptoms P2’s psychotropic medications are prescribed to alleviate;

· collect and report on medication and symptom-related data as instructed by the provider for P3 and P5;

· document a description of the target symptoms P4’s psychotropic medications are prescribed to alleviate, how you will monitor and measure changes of the target symptoms to be alleviated by the psychotropic medication; and

· maintain documentation of monitoring data that is provided to the support team and prescribe as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

9. Citation: Minnesota Statutes, section 245D.06, subdivision 1.

Violation: For one person whose record reviewed (P2), the license holder did not report an incident as required.

P2 was involved in an incident that occurred on December 20, 2024. The license holder did not report the incident to P2’s legal representative and case manager within 24 hours of occurrence. P2’s case manager and legal representative were notified of this incident on December 23, 2024.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

10. Citation: Minnesota Statutes, section 245D.06, subdivision 4.

Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not obtain written authorization to safekeep funds and other property as required.

a. The license holder obtained an authorization to safekeep P1’s funds on May 2, 2024. This authorization did not document the preferences of P1’s legal representative and case manager the frequency of receiving statements that itemized receipts and disbursements of funds. In addition, the license holder did not obtain this authorization annually in 2025.

b. The license holder did not obtain an authorization to safekeep funds and other property for P4 within five days of service initiation. The license holder initiated services with P4 on June 29, 2023. The license holder obtained authorization to safekeep funds and other property from P4 on July 14, 2023. Additionally, in August 2023, P4 obtained a legal representative. The license holder did not obtain authorization from P4’s legal representative to safekeep funds and other property for P4 annually in 2024. As of the date of the review, this authorization had not been obtained.

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

· obtain an authorization for the safe keeping of P1’s funds and ensure the information above is included; and

· obtain an authorization for the safekeeping of funds and property from P4’s legal representative.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not complete initial assessment and service planning as required.

The license holder held an initial planning meeting on November 27, 2024, however, the license holder did not include P2 at the initial planning meeting. The license holder, P2’s legal representative, P2’s case manager, other members of the support team or expanded support team did not determine at the initial planning meeting P2’s preferences for how services and supports are provided, including how the provider will support P2 to have control of P2’s schedule.

Corrective Action Ordered: Within 30 days of receiving this order, you must discuss with P2, P2’s legal representative, P2’s case manager, and other members of the support team, P2’s preferences for how services and supports are provided, including how the provider will support P2 to have control of P2’s schedule. On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For four persons whose records were reviewed (P1, P2, P4, and P5), the license holder did not develop service outcomes and supports as required.

a. The license holder did not maintain the following information for P1’s outcome:

· the methods or actions that would be used to support to the person and to accomplish the service outcome, including information about:

o any changes or modifications to the physical and social environments necessary when the service supports were provided;

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

· how data would be collected; and

· the names of the staff responsible for implementing the support and methods.

b. The license holder did not develop a service plan for P2 that documented the measurable and observable criteria for identifying when the desired outcome has been achieved and how data would be collected.

c. The license holder did not maintain the following information for P4’s outcome:

· any changes or modifications to the physical and social environments necessary when the service supports were provided; and

· the names of the staff or position responsible for implementing the supports and methods for P4’s outcomes.

d. The license holder did not collect service outcome data for P5 as described. The license holder indicated that ‘yes’ or ‘no’ should be documented daily for P5’s service outcomes. Between May 17, 2025, and June 15, 2025, the license holder did not collect data on 29 of the 30 days.

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

· document the information listed above for P1;

· document the information listed above for P2;

· document the information listed above for P4; and

· collect data for P5’s service outcomes as indicated in the plan.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not complete service review and evaluation as required.

a. The license holder did not meet with P4, P4’s legal representative, and P4’s case manager at least once per year, to discuss options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. Additionally, the license holder did not summarize P4’s status and progress toward achieving identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementations of supports and methods in a report made available at the time of the progress review meeting.

b. The license holder did not meet with P5 and P5’s case manager at least once per year to determine whether changes were needed for P5’s service plan.

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

· meet with P5, P5’s case manager, and other people as identified by P5 to discuss:

o how technology might be used to meet the person’s desired outcomes;

o options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider;

· summarize P5’s status and progress toward achieving P5’s identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting;

· provide the support plan addendum to P5 and P5’s case manager within ten working days of the progress review meeting and obtain dated signatures from P5 and P5’s case manager to document approval of any changes to the support plan addendum.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For five persons whose records were reviewed (P1-P5), the license holder did not maintain the person served record as required.

a. The license holder did not maintain daily progress notes for P1.

b. The license holder did not maintain copies of progress review reports for P2, P3, P4 and P5. The license holder documented they would provide progress review reports quarterly for P2, P3, P4 and P5; however, there were no progress review reports in the service recipient records for P2, P3, P4 or P5.

c. The license holder did not maintain a signed statement authorizing the license holder to act in a medical emergency when P4’s legal representative cannot be reached or is delayed in arriving.

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

· begin maintaining progress or daily log notes for all service recipients; and

· obtain a signed statement from P4’s legal representative authorizing you to act in a medical emergency when P4’s legal representative cannot be reached or is delayed in arriving.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not make available policies and procedures as required.

a. The license holder did not inform P2 and P2’s case manager of the policies and procedures affecting P2’s rights and provide copies of those policies and procedures within five working days of service initiation, including:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy requirements.

The license holder initiated services with P2 on October 16, 2024. P2’s legal representative and case manager were provided with the grievance policy and procedure on June 13, 2025. There was no documentation of P2’s legal representative and case manager being informed of and provided copies of the other policies required.

b. The license holder did not inform P4 and P4’s case manager of the policies and procedures affecting P4’s rights and provide copies of those policies and procedures within five working days of service initiation including:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy requirements.

The license holder initiated services with P4 on June 29, 2023, and provided these policies to P4 on July 14, 2023. There was no documentation of P4’s case manager receiving the policies and procedures.

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

· provide to P2 and P2’s case manager copies of the following policies affecting P2’s rights:

o service suspension policy and procedure;

o service termination policy and procedure;

o emergency use of manual restraints policy and procedure; and

o data privacy requirements;

· documentation of these policies being provided to P2 and P2’s case manager must be maintained in P2’s service recipient record; and

· provide to P4’s case manager copies of the policies and procedures affecting P4’s rights including:

o grievance policy and procedure;

o service suspension policy and procedure;

o service termination policy and procedure;

o emergency use of manual restraints policy and procedure; and

o data privacy requirements; and

· documentation of these policies and procedures must be maintained in P4’s service recipient record as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

16. Citation: Minnesota Rules, part 9544.003, subpart 1

Violation: For four persons whose records were reviewed (P1, P3-P5), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate P1’s, P3’s, P4’s, and P5’s positive support strategies at least every six months.

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

· evaluate with P1, P3, P4, and P5 the positive support strategies to be used when providing services; and

· based upon the evaluation, determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

17. Citation: Minnesota Rules, part 9544.0080, subpart 2.

Violation: For one person whose record was reviewed (P4), the license holder did not provide notice to the legal representative as required.

The license holder did not provide notice of the emergency use of manual restraints policy to P4’s legal representative as required.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide to P4’s legal representative, a copy of your emergency use of manual restraints policy and obtain written acknowledgement from P4’s legal representative that they have been notified of the policy. On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

18. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For seven of seven staff persons whose records were reviewed (SP1-SP7), the license holder did not provide training on the program abuse prevention plan (PAPP) as required.

a. The license holder did not provide annual training to SP1 on the license holders PAPP. SP1 last received this training in August 2020. Additionally, SP1 works at multiple locations and there was no documentation that SP1 was oriented to each individual PAPP for the service locations they worked at.

b. The license holder did not provide annual training to SP2 on the license holders PAPP. SP2 last received this training in February 2024.

c. The license holder did not provide annual training to SP3 on the license holders PAPP. SP3 last received this training in December 2023.

d. The license holder did not provide annual training to SP4 on the license holders PAPP. SP4 last received this training in October 2023.

e. The license holder did not provide annual training to SP5, SP6, and SP7 on the license holders PAPP in 2023 and 2024.

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

· provide SP1-SP7 with training on your program abuse prevention plan (PAPP);

· audit all personnel records to ensure staff have received annual training on the PAPP as required;

· for any staff that work at multiple locations, you must ensure the staff have received orientation to the PAPP for each service site they work at;

· for any staff identified in the audit to not have received annual training to the PAPP, you must provide training to the PAPP; and

· you must develop and implement a corrective action plan to ensure all staff receive annual training on the PAPP as required. The results of the audit, corrective action and the corrective action plan must be maintained in the program files for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For four staff persons whose records were reviewed (SP1-SP4), the license holder did not provide orientation as required.

a. The license holder did not provide and ensure completion of orientation for SP1, SP2, SP3 and SP4 in the following areas:

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

o grievance and complaint policy and procedures;

o temporary service suspension policy and procedures;

o service termination policy and procedures;

o emergency use of manual restraint policy and procedures;

o health service coordination and care policy and procedures;

o safe transportation policy and procedures; and

o service admission policy; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

b. SP2 was hired on January 31, 2024. The license holder did not provide orientation to SP2 in the following areas within 60 days of hire:

· the service recipient rights, and staff responsibilities related to ensuring the exercise and protection of those right according to the requirements in Minnesota Statutes, section 245D.04. The license holder provided this orientation in January 2025;

· data privacy requirements according to Minnesota Statutes, section 13.01 to 13.10 to 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices. The license holder provided this orientation in January 2025.

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

· provide and ensure completion of orientation to SP1, SP2, SP3, and SP4 in the above listed areas;

· maintain documentation of this orientation in the personnel record including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor;

· audit current personnel records to ensure all staff have received orientation in the above listed areas;

· for any staff identified to not have received orientation, orientation must be provided and documented in the personnel record as required; and

· based on the results of the audit, you must develop and implement a plan to ensure all staff receive orientation on the above listed topics as required. This plan must be maintained in the program files for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

20. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For seven staff persons whose record were reviewed (SP1-SP7), 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 did not provide SP1 with the following trainings annually:

· the principles for person centered service delivery and planning as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person The license holder last provided this training to SP1 in August 2020; and

· basic first aid. The license holder last provided this training to SP1 in September 2020.

b. The license holder did not provide SP2 with annual training on the principles for person centered service delivery and planning as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder last provided this training in February 2024.

c. The license holder did not provide SP3 with the following trainings annually in 2024:

· the principles for person centered service delivery and planning as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder last provided this training in December 2023; and

· basic first aid. The license holder last provided this training in December 2023.

d. The license holder did not provide SP4 with the following trainings annually in 2024:

· the principles for person centered service delivery and planning as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder last provided this training to SP4 in October 2023; and

· basic first aid. The license holder last provided this training to SP4 in December 2023.

e. The license holder did not provide SP5 with the following trainings annually:

· the principles for person centered service delivery and planning as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder last provided SP5 with this training in February 2023;

· basic first aid. The license holder last provided this training to SP5 in February 2023 and April 2025.

f. The license holder did not provide SP6 with the following trainings annually:

· data privacy requirements according to Minnesota Statute, section 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 license holder did not provide SP6 with this training in 2023, 2024, and 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 did not provide SP6 with this training in 2023, 2024, and 2025;

· the principles of person-centered service planning service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to the direct support service provided by the staff person. The license holder last provided SP6 with this training in November 2022; and

· basic first aid. The license holder last provided this training in April 2023.

g. The license holder did not provide SP7 with the following trainings annually:

· data privacy requirements according to the Minnesota Statutes, section 13.01 to 13.10, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices. The license holder did not provide SP7 with these trainings in 2023, 2024, and 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 did not provide SP7 with these trainings in 2023, 2024, and 2025;

· the principles for person centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder last provided SP7 with this training in December 2022; and

· basic first aid. The license holder provided SP7 with this training in April 2021 and January 2024.

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

· provide SP1, SP2, SP3, SP4, SP5, SP6 and SP7 with the training listed above that they have not received in the previous 12 months;

· audit all personnel records to ensure staff have received training to all annual requirements in the previous 12 months;

· for any staff identified to not have received annual training as required, training must be provided;

· documentation of any training provided including the date of completion, number of hours per subject area, and the name of the instructor or trainer must be maintained in the personnel record as required;

· based upon the results of the audit, you must develop and implement a plan to ensure all staff receive annual training as required on an ongoing basis. You must maintain documentation of the audit, corrective action, and corrective action plan in the program files for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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

Violation: For six persons whose record were reviewed (SP1, SP2, and SP4-SP7), the license holder did not maintain personnel records as required.

The license holder did not document the number of hours per subject area and the name of the instructor on SP1’s, SP2’s, SP4’s, SP5’s, SP6’s and SP7’s trainings.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

22. Citation: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c).

Violation: The license holder did not establish a prohibition of drug and alcohol use policy as required.

The license holder did not establish a policy that prohibited license holders, employees, subcontractor, and volunteers, when directly responsible for persons served by the program, from being in any manner under the influence of a chemical that impaired the individual’s ability to provide services or care.

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

· establish a prohibition of drug and alcohol use policy that meets the requirements outlined above;

· provide staff with an orientation to the updated policy; and

· maintain documentation of the date the orientation is completed, the number of hours per subject area, and the name of the trainer or instructor in the personnel record as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

23. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b).

Violation: The license holder did not establish a maltreatment of vulnerable adults reporting policy as required.

The license holder did not identify in the maltreatment of vulnerable adults reporting policy, the primary and secondary person or position who would ensure that, when required, internal reviews were completed and identified the secondary person would be involved when there was reason to believe that the primary person was involved in the alleged or suspected maltreatment.

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

· identify the primary and secondary person or position responsible for ensuring internal reviews are completed;

· require that the secondary person is responsible for the review when there is a reason to believe the primary person was involved in the alleged or suspected maltreatment;

· provide orientation on the updated maltreatment reporting policy to all persons served and maintain documentation of this orientation in the service recipient record as required; and

· provide orientation to all staff on the updated maltreatment reporting policy and maintain documentation of this orientation, including the date the orientation is completed, the name of the trainer or instructor, and the number of hours per subject area in the personnel record as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

24. Citation: Minnesota Statutes, section 245D.10, subdivision 2.

Violation: The license holder did not establish policies and procedures that promoted service recipient rights by providing a simple complaint process as required.

The license holder did not establish a grievance policy that required staff to assist with the complaint process when requested, including providing the addresses and telephone number of outside agencies to assist the service recipient.

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

· update your grievance policy to include the requirements above;

· provide all persons served, legal representatives, and case managers with a copy of the updated policy and maintain documentation of this distribution in the service recipient record as required; and

· provide orientation to all staff on the updated policy and maintain documentation of this orientation, including the date the orientation was provided, name of the instructor or trainer, and number of hours per subject area, in the personnel record as required.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

25. Citation: Minnesota Statutes, section 245D.081, subdivision 2 and 3.

Violation: The license holder did not ensure program coordination of service delivery and evaluation of services, program management, and program oversight as required.

a. The license holder did not ensure the delivery and evaluation of services provided by the license holder were coordinated by a designated staff person that provided supervision, support, and evaluation including:

· oversight of the license holder’s responsibilities assigned in the person’s support plan and the 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 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.

b. The license holder did not ensure the designated manager provided program management and oversight of the services provided by license holder including:

· 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), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g);

· ensuring the duties of the designated coordinator were fulfilled according to the requirements in subdivision 2;

· 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);

· ensuring and protecting each person’s rights as identified in 245D.04;

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

The lack of program coordination and evaluation of individual service delivery along with the lack of program management and oversight is evidenced in citations 1 through 24.

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

· ensure the staff persons identified as designated coordinators meet the requirements outlined in 245D.081, subdivision 2, paragraph (b) and maintain documentation of how these individuals meet the criteria in the personnel record as required;

· ensure the staff person(s) identified as the designated manager meet the requirements outlined in 245D.081 subdivision 3, paragraph (b) and maintain documentation of how the individual(s) meet the requirements in the personnel record as required; and

· review with the designated coordinators and designated manager(s) the assigned job duties and maintain a signed document that indicates the staff understand and acknowledge the job duties assigned to them.

Additionally, within 60 days of receiving this order, you must submit to your licensor a written plan detailing how compliance will be achieved and maintained in the following areas:

· medication administration to persons served as outlined in 245D.05, subdivision 2;

· staff orientation training as defined in 245D.09; and

· staff annual training as defined in 245D.09.

On an ongoing basis, you must maintain compliance as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit.

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 erin.white1@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: Erin White

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.

Erin White, Home and Community Based Services Licensor

Licensing Division

Office of Inspector General

651-431-4821

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