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August 28, 2025 CERTIFIED MAIL Abdurahman Jama, Authorized Agent Mercy Link LLC 7400 Metro Boulevard Suite 150 Edina, Minnesota 55439 License Number: 1080519 (Home and Community – Based Services)
ORDER OF CONDITIONAL LICENSE Dear Abdurahman Jama: The Department of Human Services (DHS) is placing your license to provide at Mercy Link LLC, 7400 Metro Boulevard, Edina, Minnesota, on conditional status for two years, beginning August 28, 2025. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Home and Community Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE Licensing Violations Determined on June 18, 2025 DHS determined that your program did not follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violation 1. Violation: The license holder did not meet the requirements for program management and oversight. a. The license holder identified SP3 as the designated coordinator. The license holder did not ensure SP3 provided supervision, support, and evaluation of activities that included: · providing 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; · providing 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 · evaluating 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 outcomes has been achieved according to the requirements in section 245D.07. b. The license holder identified SP4 as the designated manager; however, the license holder did not ensure SP4 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. c. The license holder identified SP4 as the designated manager. The license holder did not ensure that SP4 provided program management and oversight of the services provided. See citations 1 through 18 for the designated manager’s lack of responsibility to: · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; and · ensuring corrective action was taken when ordered by the commissioner. The license holder was issued a Correction Order on March 14, 2025. In response to the Correction Order, the license holder developed a corrective action plan that stated, “Corrections will be completed by April 14, 2025. DM/DC staff is accountable for the oversight of complet[ing] of these corrections.” The license holder did not ensure corrective action was taken as evidenced in citation 1 through 18. Statute Violated: Minnesota Statutes, section 245D.081, subdivision 2 and 3. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. Person Served Violations 1. Violation: For one of four persons whose record was reviewed (P3), the license holder did not provide orientation to the internal and external reporting procedures and the program abuse prevention plan (PAPP) as required. P3’s service initiation was February 25, 2025. The license holder did not provide P3’s legal representative and case manager an orientation to the internal and external reporting procedures an PAPP within 24 hours of admission. Statute Violated: Minnesota Statutes, Section 245A.65, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 2. Violation: For three persons whose records were reviewed (P1, P3 and P4), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder maintained IAPPs for P1 and P4 that assessed P1 and P4 were not susceptible to abuse or at risk of abuse of other vulnerable adults. The assessments was inconsistent with the information reviewed elsewhere in P1’s and P4’s record. The license holder did not include an accurate and individualized assessment of P1’s and P4’s susceptibility to abuse. b. The license holder did not develop an IAPP for P3 that included statements of the specific measures to be taken to minimize the risk of abuse to P3 and other vulnerable adults. Statute Violated: Minnesota Statutes, Section 245A.65, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 3. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not provide service recipient rights as required. The license holder did not provide P3 and P4 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. Statute Violated: Minnesota Statutes, Section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 4. Violation: For one person whose record was reviewed (P3), the license holder did not meet the requirements for medication administration. The license holder was assigned responsibility to administer medications to P3. The license holder did not obtain written authorization from P3’s legal representative to administer medication prior to administering medication. Statute Violated: Minnesota Statutes, Section 245D.05, subdivision 2. 5. Violation: For one person whose record was reviewed (P3), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. "Target symptom" refers to 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.
P3 was prescribed psychotropic medications and the license holder was responsible for administering medications to P3. The license holder did not maintain documentation in P3’s support plan addendum that included a description of the target symptoms that each psychotropic medication was to alleviate. Statute Violated: Minnesota Statutes, Section 245D.051, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 6. Violation: For one person whose record was reviewed (P3), the license holder did not obtain written authorization for safekeeping of funds as required. The license holder did not obtain written authorization to assist P3 with the safekeeping of funds from P3’s legal representative and P3’s case manager within five working days of service initiation. The license holder initiated services for P3 on February 25, 2025 and obtained written authorization from P3’s case manager to assist P3 with the safekeeping of funds on June 16, 2025. Statute Violated: Minnesota Statutes, Section 245D.06, subdivision 4. 7. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not complete assessments and service planning for intensive support service as required. a. The license holder did not complete an assessment of P4’s ability to self-manage health and medical needs, including chronic medical conditions. The licnese holder completed an assessment for P4’s ability to self-manage a chronic medical condition that was inconsistent with the information reviewed elsewhere in P4’s record. b. The license holder did not have a discussion of how technology might be used to meet P3’s and P4’s desired outcomes and maintain a summary of this discussion in P3’s and P4’s support plan addendum that included: · 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. Statute Violated: Minnesota Statues, Section 245D.071. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 8. Violation: For one person whose record was reviewed (P4), the license holder did not develop service outcomes and supports as required. The license holder did not develop a service plan for 4 that documented supports and methods, including: · techniques that were consistent with P4’s communication mode and learning style; and · the names of the staff or position responsible for implementing the supports and methods. Statute Violated: Minnesota Statutes, Section 245D.071, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 9. Violation: The license holder did not keep a written or electronic admission and discharge register as required. The license holder did not keep a written or electronic register, listing in chronological order the dates and names of all the persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder and deaths. Statute Violated: Minnesota Statutes, Section 245D.095, subdivision 2. 10. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not maintain service recipient records as required. a. The license holder did not maintain a signed statement for P3 authorizing the license holder to act in a medical emergency when P3’s legal representative cannot be reached or delayed in arriving. b. The license holder did not maintain progress or daily notes for P4 that were recorded by the program. c. The license holder did not protect service recipient records against loss. The license holder reported to DHS licensors that documentation for P3’s service initiation on February 25, 2025 was lost. Statute Violated: Minnesota Statutes, Section 245D.095, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 11. Violation: For one person whose record was reviewed (P3), the license holder did not inform and provide written or electronic copies of the policies and procedures as required. The license holder did not inform P3 and case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation: · grievance policy and procedures; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. The license holder initiated services for P3 on February 25, 2025. The license holder provided copies of the required policies to P3 on June 6, 2025 and to P3’s case manager on June 16, 2025. Statute Violated: Minnesota Statutes, Section 245D.10, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 12. Violation: For one person whose record was reviewed (P1), the license holder did not evaluate positive supports strategies as required. The license holder did not evaluate positive support strategies with P1 at least every six months. Rule Violated: Minnesota Rules, part 9544.0030, subpart 1. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same rule. 13. Violation: For one person whose record was reviewed (P3), the license holder did not obtain a written acknowledgement from the person’s legal representative when the license holder informed the person of the license holder’s policy on the emergency use of manual restraint as required. The license holder did not obtain a written acknowledgment from P3’s legal representative indicating that P3 and P3’s legal representative had been notified of the license holder’s emergency use of manual restraints policy. Rule Violated: Minnesota Rules, part 9544.0080, subpart 1 and 2. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. Staffing Standards Violations 14. Violation: For four of seven staff persons whose records were reviewed (SP1, SP2, SP5 and SP6), the license holder did not provide orientation to mandated reporters as required. The license holder did not provide SP1, SP2, SP5, and SP6 orientation to the license holder’s program abuse prevention plan (PAPP) within 72 hours of first providing direct contact services. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 15. Violation: For two staff persons whose records were reviewed (SP5 and SP6), the license holder did not provide orientation training as required. The license holder did not provide SP5 and SP6 with orientation to basic first aid within 60 calendar days of SP5’s and SP6’s hire. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 16. Violation: For two staff persons whose records were reviewed (SP5 and SP6), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide SP5 and SP6 with an orientation to individual service recipient needs before having unsupervised direct contact with a person served by the program. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. 17. Violation: For two staff persons whose records were reviewed (SP5 and SP6), the license holder did not maintain personnel records as required. a. The license holder did not maintain a personnel record for SP5 that documented the following: · date of first supervised direct contact with a person served by the program; and · date of first unsupervised direct contact with a person served by the program. b. The license holder did not maintain a personnel record for SP6 that included documentation of training, including the name of the trainer or instructor. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on March 14, 2025, you were previously found in violation of this same statute. Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite ongoing. If you fail to demonstrate substantial compliance with home and community-based services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Nature, chronicity, or severity of violations and effect of violation(s) on health, safety, or rights of persons served by the program The Commissioner has considered the nature, chronicity, or severity of the violation(s) of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a conditional license is appropriate. · Nature: DHS determined you were responsible for 18 licensing violations related to the health, safety, and rights of the persons served. · Chronicity: Your program received its license on February 26, 2016. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o August 28, 2025 Conditional License (this order): 18 violations (11 repeat) o March 14, 2025 Correction Order: 18 violations o April 19, 2019 Correction Order: 9 violations o April 14, 2025 Order to Pay a Fine: Background Study Violation $600 fine · Severity: You did not conduct an initial planning meeting for P4. This meeting is important in determining and documenting what the service is going to look like for the person served and how the license holder will provide supports to the person served in their areas of needs. This knowledge and documentation isessential in implementing person centered services and this lack of documented documentation could affect their services. Additionally, this documentation informs the staff of their responsibilities for carrying out and implementing such planning. You did not develop individual abuse prevention plans that were individualized based off the assessment of the person served and included specific measures to be taken to reduce the risk of abuse to the person, which could negatively impact the health and safety of persons served. Individual abuse prevention plans provide staff with knowledge of potential risks and strategies to reduce the risk. By not including all areas of potential risks and specific measures to be taken in the individual abuse prevention plans, you did not ensure staff had knowledge of the persons risks and the specific measures to be taken to reduce the risk of abuse, thereby putting the health and safety of the persons you served at risk. The license holder did not provide orientation training to direct support staff persons, including training on maltreatment reporting requirements and individual needs. When direct support staff are not provided with orientation training, staff may not be competent to provide services to persons and there is an increased risk of neglect or abuse to persons served by the program. Training staff is a critical part of ensuring persons served are kept safe and to ensure their rights are protected. The failure to provide staff training directly relates to health, safety, and well-being of persons served by the program. The designated coordinator and designated manager did not provide the coordination of service delivery and evaluation of the program manament and oversight which is required to ensure your program remains in compliance with the licensing requirements. In addition, SP4 did not meet the qualifications of the designated manager and the license holder did not appoint a new designated manager as ordered in the correction order on March 14, 2025. License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of your inability to hire a qualified designated manager and your inability to ensure your designated manager fulfilled their responsibilities, your were cited for 18 violations as described in this order. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community based services is placed on a conditional status. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of: · the program’s operation; · well-being of persons served by your program; · available evaluations of the program by persons receiving services; · information about the qualifications of the direct support staff employed by you; · the ability to demonstrate competent knowledge of applicable laws and rules; and · the results of background studies. DHS is concerned about your program’s operation, well-being of persons served by your program, qualifications of staff and your ability to demonostrate competent knowledge of applicable laws. DHS is concerned about the programs operation because since it was license in 2016, DHS has issued 2 correction orders, a background study fine, a conditional license, and 18 violations determined during the most recent licensing reviews. The number of violations, and the fact that many were repeat violations, demonstrates that you have not adequately overseen your responsibilities as a license holder, to ensure compliance, and to take corrective action when ordered by the commissioner. You did not comply with service planning and record keeping requirements, including violations in which you did not complete corrective action as ordered in the previous correction order. These requirements protect the health and safety of persons servied and are minimum standards for license holders. To not comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Record keeping and service planning requirements are essential to keeping vulnerable adults safe and ensuring the persons served are receiving necessary services. Your lack of service planning and documentation posed a risk that staff would not know about the unique needs of the vulnerable people served. Your inability to hire a qualified designated manager calls into question your ability to follow the applicable laws and rules; to be able to operate a program; and to ensure the well-being of persons served. A qualified designated manager is critical as they provide oversight of the license holder’s responsibilities.Your failure to identify a qualified individual for this position indicates that you are either unable or unwilling to comply with the licensing requirements. Based on the Commissioner’s evaluation of the program, a conditional license is warranted. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community based services is on a conditional license. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the 18 violations (11 repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. The violations involved your lack of competence to ensure the duties and responsibilities of the designated manager were met. Due to the lack of oversight, you did not ensure the designated manager identified and implemented corrective action ordered by the commissioner in previous actions. The violations also involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, therefore, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a managerial staff person, other than SP4, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the person(s) who will fulfill the duties and responsibilities of your designated manager for DHS review and approval. It is your responsibility to ensure that your designated manager meets the necessary qualifications. You must maintain documentation of your designated manager’s qualifications in their personnel record and maintain a signed job description in their personnel record. Changes to these positions may not be made without prior notification and approval by DHS. 3. Within 30 days of receiving this order, you must: · submit a written plan to DHS detailing how you will ensure the corrective action ordered in this order is completed; · submit a written plan to DHS detailing how you will audit all persons served and staff records for compliance with all applicable rules and statutes; and · submit documentation that your program’s designated coordinator and designated manager have reviewed their roles and responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3. 4. Within 60 days of receiving this order, you must: · complete an audit of all participant and personnel records according to your written plan. The audit must be completed by your designated coordinator and/or designated manager; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · submit the date to your DHS licensor that all person served and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order. 5. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 6. You may not add additional services to your HCBS license without prior approval from DHS for the duration of the conditional license. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all HCBS laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, Supervisor, at 651-431-6591. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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