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NOTICE: The Amended Correction Order supersedes the original Correction Order dated July 8, 2025. This document is amended to correctly document the evidence statement for part b of citation 4, the violation statement of citation 5 to include P2, to correctly document part b of citation 5, and to include part d of citation 5. Date issued: July 8, 2025 Date reissued: August 12, 2025 Shamso Abdi, Authorized Agent Empire Resources LLC 1821 University Avenue West STE 146 Saint Paul, Minnesota, 55104 License Number: 1111950 (245D – HCBS) AMENDED CORRECTION ORDER Dear Shamso Abdi: On June 3, 2025, a licensing review of Empire Resources LLC, located at 1821 University Avenue W STE 146, 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.04, subdivision 5. Violation: For four of six persons whose records were reviewed (P3, P4, P5 and P6), the license holder did not ensure commissioner’s right of access as required. At the time of the licensing review on June 3, 2025, DHS licensors requested P3’s, P4’s, P5’s, and P6’s service recipient records. The license holder stated SP3 had taken P3’s, P4’s, P5’s and P6’s service recipient records home and the license holder was unable to provide access to the records over the course of over three hours. The license holder did not ensure the commissioner was given access to P3’s, P4’s, P5’s and P6’s service recipient records. Corrective Action Ordered: Immediately upon receiving this order, you must ensure that records are maintained in a manner that is accessible to the commissioner. The commissioner must be given access without prior notice and as often as the commissioner considers necessary if the commissioner is investigating alleged maltreatment, conducting a licensing inspection, or investigating an alleged violation of applicable laws or rules. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two 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 did not develop an IAPP for P1 that 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. b. The license holder initiated P2’s services on May 8, 2024. The license holder did not develop an IAPP for P2 as part of the initial individual program plan or service plan prior to upon service initiation. Corrective Action Ordered: Immediately upon receiving this order, you must develop an IAPP for P1 and P2 that includes: · an individualized assessment of P1’s and P2’s susceptibility to abuse; · include a statement of the specific measures that your program will take to minimize those risks of abuse and provide specific support instructions to staff persons implementing P1’s and P2’s plans; and · review P1’s and P2’s IAPP with the person’s case manager and members of their support team. You must document the review of the IAPP in P1’s and P2’s service recipient record. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the service recipient rights as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year.
a. The license holder did not provide P1 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation and annually thereafter. b. The license holder provided multiple services to P2. The license holder did not provide P2 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of each additional service initiation and annually in 2025. The license holder initiated services for P2 in May, August, and September 2024 but only provided P2 the required written notice in May 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 and P2 with a copy of the service recipient rights and an explanation of those rights; · maintain documentation of the receipt of the rights and an explanation of the rights in P1’s and P2’s service recipient records; and · complete an audit of the persons served by your program to ensure all persons served have been provided a copy of the service recipient rights and an explanation of those rights. Compliance with this order will be reviewed onsite 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.05, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain documentation of how the person’s health needs would be met as required. a. The license holder was assisting P1 with coordinating medical appointments, including providing transportation to medical appointments. The license holder did not maintain documentation in P1’s support plan addendum that included a description of the procedures the license holder would follow in order to assist P1 with coordinating medical appointments. b. The license holder did not maintain documentation in P1’s support plan addendum that included a description of the procedures the license holder would follow in order to provide medication assistance and assist with or coordinate medical, dental, and other health service appointments to P2. Corrective Action Ordered: Immediately, you must review and revise P1’s and P2’s support plan addendums to include the above-mentioned information. You must review the revisions to P1’s and P2’s support plan addendums with P1’s and P2’s expanded support teams. Compliance with this order will be reviewed onsite 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.07, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete service planning requirements for basic support services as required. a. The license holder did not complete a preliminary support plan addendum for P1, based on the support plan, within 15 calendar days of service initiation. The license holder initiated a service for P1 on May 8, 2023. The license holder developed P1’s support plan addendum on May 6, 2024. b. The license holder did not complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation for services that were initiated for P2 on August 28, 2024, and September 4, 2024. c. According to P1’s and P2’s support plan addendum, the license holder was assigned responsibility of participating in annual service planning and support team meetings. The license holder did not participate in P1’s service planning and support team meetings annually in 2024 and 2025, and P2’s service planning and support team meetings annually in 2025. d. The license holder failed to review and revise P2’s preliminary support plan addendum to document the individualized home support service that will be provided including how, when, and by whom services will be provided within 60 calendar days of individualized home support services being initiated on May 8, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P2’s support plan addendum to include how each of P2’s services will be provided, including how, when, and by whom; and · meet with P1’s and P2’s support team or expanded support team and maintain documentation of this meeting in P1’s and P2’s service recipient records. Compliance with this order will be reviewed onsite 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.07, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide progress review reports as required. According to P1’s and P2’s support plan addendum, the license holder was assigned the responsibility of providing P1, P2, and their case managers written reports annually. The license holder did not provide written reports annually to: · P1 and P1’s case manager in 2024 and 2025; and · P2 and P2’s case manager in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1, P2, and their case managers and support teams with a written report regarding P1’s and P2’s status or progress; and · maintain the progress review reports in P1’s and P2’s service recipient records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rule, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate positive support strategies as required. The license holder did not incorporate positive support strategies in writing to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Immediately, you must incorporate positive support strategies into P1’s and P2’s existing support plan addendum. Additionally, the positive support strategies must be evaluated at least every six months with P1 and P2 to determine whether changes are needed, and if so, make appropriate changes. Compliance with this order will be reviewed onsite 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 two persons whose records were reviewed (P1 and P2), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes that were recorded by the program in P1’s and P2’s service recipient record. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for P1 and P2. Compliance with this order will be reviewed onsite 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.10, subdivision 4 and Minnesota Rules, 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide policies and procedures as required. The license holder did not inform P2’s case manager of the following policies and procedures and did not provide copies within five working days of P2’s initiation of individualized home supports service: · grievance policy and procedure; · service suspension; and · service termination policy and procedure. Additionally, the license holder did not inform and provide P2 and P2’s case manager of the policies and procedures listed above and did not provide copies within five working days of initiating additional services in August and September 2024. The license holder did not notify P2 of the license holder’s emergency use of manual restraints policy, and their rights under this chapter and Minnesota Statutes, section 245D.04 upon service initiation for each service. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P2 and P2’s case manager with the policies and procedures listed above; · provide P2 with a notification of your emergency use of manual restraints policy; · obtain written acknowledgement from P2 that P2 was notified of your policy on emergency use of manual restraints; and · maintain this acknowledgement in P2’s service recipient record. Compliance with this order will be reviewed onsite 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 4. Violation: For three of three staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide orientation training as required. a. The license holder did not provide SP1 and SP3 orientation training on the following topics within 60 days of hire: · a job description and how to complete specific job functions including: o responding to and reporting incidents as required in Minnesota Statutes, section 245D.06, subdivision 2; and o following safety practices established by the license holder and 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 13.46, 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; · 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; · 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; · 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 health relationships, consent, and bodily autonomy of people with disabilities. b. The license holder did not provide SP2 with the following orientation within 60 days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder and 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, access, and staff responsibilities related to the implementation of those policies and procedures; · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply 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 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. This was provided to SP2 on September 19, 2024; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. This was provided to SP2 on September 19, 2024. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP1, SP2, and SP3 with the training listed above. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP3), 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 SP3 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. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide the orientation listed above to SP1 and SP3 for each service recipient that the staff person provides direct support services to. On an ongoing basis, you must maintain compliance as required with this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training as provided. 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 SP2 and SP3 annual training on the following topics in 2025: · 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 (HIPAA), 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, 245A.66, and 626.557 and chapter 260E, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP2 and SP3 with the above-mentioned annual training; · maintain documentation of this training in SP2’s and SP3’s personnel record; · audit the personnel records of all direct support staff to ensure they have been provided annual training. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP1, SP2 and SP3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a personnel record for SP1, SP2 and SP3 that contains the following information: o the employee’s date of hire; o the date the training was completed; o the number of hours per subject area; o the name of the trainer or instructor; o the employee’s date of first supervised and unsupervised direct contact with the person served; and · audit the personnel records of all direct support staff to ensure they include the above-mentioned information. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder did not establish policies and procedures related to suspected or alleged maltreatment that identified the primary person or position: · to whom internal reports may be made and is responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5; and · who will ensure that, when required, internal reviews are completed. The primary person that was identified in the license holder’s policy and procedures was not longer employed with the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must establish a policy and procedures related to suspected or alleged maltreatment as detailed above. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not provide program management and oversight as required. a. The license holder did not ensure that the designated coordinator (SP4), provided supervision, support, and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the 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. Additionally, the license holder did not ensure that SP4 minimally had: · a baccalaureate degree in a field related to human services, education, or health and one year of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older, or equivalent work experience providing care or education to vulnerable adults or children; · an associate degree in a field related to human services, education, or health and two years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older, or equivalent work experience providing care or education to vulnerable adults or children; · a diploma in a field related to human services, education, or health from an accredited postsecondary institution and three years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older or equivalent work experience providing care or education to vulnerable adults or children; or · a minimum of 50 hours of education and training related to human services and disabilities; and · a minimum of four years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older under the supervision of a staff person who meets the qualifications identified in clauses (1) to (3). b. The license holder did not ensure the designated manager (SP3) provided program management and oversight of the services provided by the 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); · ensuring the duties of the designated coordinator were fulfilled according to 245D.081, subdivision 2; · ensuring staff competency requirements were met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training was provided according to the requirements in 245D.09, subdivisions 4, 4a, and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Additionally, the license holder did not ensure SP3 minimally: · met the education and training requirements identified in subdivision 2, paragraph (b); and · had a minimum of three years of supervisory level experience in a program that provided care or education to vulnerable adults or children. The lack of program coordination, management and oversight is evidenced in citations 1 through 14. Corrective Action Ordered: Within 30 days of receiving this order, you must: · designate a person other than SP4 to perform the duties of the designated coordinator that meets the qualifications according to Minnesota Statutes, section 245D.081, subdivision 2; · designate a person other than SP3 to perform the duties of the designated manager that meets the qualifications according to Minnesota Statutes, section 245D.081, subdivision 3; and · verify and document their qualifications according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. 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. Kate Spenger, Human Services Licensor Licensing Division Office of Inspector General 651-431-5757
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