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September 5, 2025 Tyler Nyhus, Authorized Agent Twin Ports Children Services Inc. 4905 Hermantown Road Hermantown, Minnesota 55811 License Number: 1085851 (245D – HCBS) 1113286 (CRS) Kirkus 1090916 (CFRS) Kirkus 1114240 (CFRS) Morgan 1116371 (CFRS) Swan Lake 1121787 (CFRS) Martin CORRECTION ORDER Dear Tyler Nyhus, On June 25-26, 2025, a licensing review of Twin Ports Children Services Inc. located at 1707 Maple Grove Road, Duluth, 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 245D.04, subdivision 1. Violation: For one of seven people whose record was reviewed (P2), the license holder did not provide a written notice that identified the service recipient rights and an explanation of those rights as required. 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 annually in 2025. Corrective Action Ordered: P2 no longer receives services. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P2), the license holder did not review the restriction of rights in the person’s support plan addendum as required. The license holder was assigned a quarterly review schedule for P2’s right restriction. The license holder did not review the need for the rights restriction based on the conditions for ending the restriction on a quarterly basis. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P2 no longer receives services. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (a) and (c). Violation: For two people whose records were reviewed (P2 and P4), the license holder did not follow medication administration procedures as required. a. During site visits that were completed during the licensing review on January 15, 2025, DHS licensors learned that P2 had continuously refused their daily scheduled 17GM Gavilax powder. Staff did not document these refusals on the MAR from July 1, 2024 through the time of the licensing review. The license holder did not ensure notation of any occurrence of a dose of medication not being administered as prescribed, whether by error by the staff or the person or by refusal by the person. Additionally, the license holder did not report to the prescriber a pattern of P2 refusing to take the medication as prescribed. b. The license holder did not ensure the notation of when a medication or treatment was administered in P4’s medication administration record on May 16, 2025. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P2 no longer receives services. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For two people whose records were reviewed (P1 and P2), the license holder did not review and report medication and treatment issues as required. The license holder did not report medication errors or refusals to P2’s legal representative and case manager as they occurred. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P2 no longer receives services. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b), clause 1. Violation: For three people whose records were reviewed (P1, P4, and P5), the license holder did not meet the requirements for psychotropic medication use and monitoring as required. Target symptoms refer 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. The license holder was assigned the responsibility of administering P1, P4, and P5’s psychotropic medications in their support plan addendums. The license holder did not maintain documentation with the description of the target symptoms that each of P1, P4, and P5’s psychotropic medications were intended to alleviate in their support plan addendums. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must maintain documentation with the description of the target symptoms that P4 and P5’s psychotropic medications are to alleviate in P4 and P5’s support plan addendums. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.06, subdivision 8 Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not meet the requirements of a positive support transition plan as required. P1’s and P4’s positive support transition plans required the expanded support teams to review the effectiveness of the plans no less than every quarter (three months) or 90 days. The license holder did not develop a positive support transition plan for P1 and P4 in the manner prescribed by the commissioner when the license holder did not review P1’s and P4’s positive support transition plans every quarter. Repeat Violation: In a correction order DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must: · review the effectiveness of the positive support transition plan for P4 with P4’s expanded support team; · if the incidence of targeted interventions has not decreased within the past six months, the license holder must submit a request to P4’s case manager or directly request the help of an external qualified professional; and · maintain this documentation in P4’s record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.061. Violation: For one person whose record was reviewed (P2), the license holder did not ensure that emergency use of manual restraints complied with the requirements of this chapter. P2 was involved in several incidents that resulted in the emergency use of manual restraint. The license holder did not: · within three calendar days after an emergency use of manual restraint, ensure the staff person who implemented the emergency use reported in writing to the designated coordinator the following information: o the staff and persons receiving services who were involved in the incident leading up to the emergency use of manual restraint; o a description of the physical and social environment, including who was present before and during the incident leading up to the emergency use of manual restraint; o a description of what less restrictive alternative measures were attempted to de-escalate the incident and maintain safety before the manual restraint was implemented that identifies when, how, and how long the alternative measures were attempted before manual restraint was implemented; o a description of the mental, physical, and emotional condition of the person who was restrained, and other persons involved in the incident leading up to, during, and following the manual restraint; o whether there was any injury to the person who was restrained or other persons involved in the incident, including staff, before or as a result of the use of manual restraint; and o whether there was a debriefing with the staff, and, if not contraindicated, with the person who was restrained and other persons who were involved in or who witnessed the restraint, following the incident and the outcome of the debriefing; · within five working days of the emergency use of manual restraint, complete internal reviews of the emergency use of manual restraints that includes an evaluation of whether: o the person's service and support strategies developed according to sections 245D.07 and 245D.071 need to be revised; o related policies and procedures were followed; o the policies and procedures were adequate; o there is a need for additional staff training; o the reported event is similar to past events with the persons, staff, or the services involved; o is there a need for corrective action by the license holder to protect the health and welfare of persons; o based on the results of the internal review, the license holder must develop, document, and implement a corrective action plan for the program designed to correct current lapses and prevent future lapses in performances by individuals or the license holder, if any; · consult with the expanded support team within five working days after the completion of the internal review to: o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identified the perceived function the behavior served; and o determine whether the person's support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint. Repeat Violation: In a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P2 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P4), the license holder did not provide services as assigned in the support plan and in compliance with the requirements of the federal waiver plan. The license holder did not provide services according to P4’s support plan, including providing the required supervision levels according to the rate exception. Repeat Violation: In a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (a), (b), and (c). Violation: For one person whose record was reviewed (P5), the license holder did not complete initial service planning as required. a. The license holder initiated P5’s services on March 7, 2025. The license holder completed a preliminary support plan addendum on April 10, 2025. The license holder did not complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation. b. The license holder did not complete assessments that identified P5’s ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and safety of the person or others. c. The license holder did not meet with P5, P5’s legal representative, P5’s case manager, other members of the support team or expanded support team before providing 45 days of service to determine the following: · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; and · how services must be coordinated across other providers under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person. Corrective Action Ordered: Within 30 days of receiving this order, you must · assess the above-mentioned information for P5 and maintain copies of the assessments in the person’s record; and · meet with P5, P5’s legal representative and case manager and other members of the support team to determine the above-mentioned information. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraphs (b) and (c). Violation: For one person whose record was reviewed (P2), the license holder did not complete ongoing service plan review and evaluation as required. The license holder did not meet with P2, P2’s legal representative, P2’s case manager, and other members of P2’s support team to discuss the following: · how technology might be used to meet the person’s outcomes; and · options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. Corrective Action Ordered: P2 no longer receives services from the license holder. On an ongoing basis you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P5), the license holder did not inform and provide policies and procedures as required. The license holder initiated P5’s services on March 7, 2025. The license holder did not inform P5’s case manager of the policies and procedures affecting a person’s rights and provide copies of those policies and procedures within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must inform P5’s case manager of the polices and procedures affecting a person’s rights and provide copies of those policies and procedures. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate with P1 the identified positive support strategies at least every six months. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: P1 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.11, subdivision 2, paragraph (3). Violation: For two persons whose records were reviewed (P6 and P7), the license holder did not implement the program’s safe medication assistance and administration policy as written. The program’s policy on safe medication assistance and administration stated that “medications that are discontinued, outdated, or have been prepared and not administered are to be collected by the company nurse and returned to the pharmacy to be destroyed. The company nurse will document when medications are destroyed.” P6’s and P7’s medication boxes contained expired medications. The license holder did not dispose of medications as required. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order you must: · review the medications for all persons served by your program to ensure medications are current and any expired or discontinued medications are disposed of; and · maintain documentation of the medication reviews you complete, including the date(s) of completion, and the name of the person(s) who completed the reviews. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota statutes, section 245D.09, subdivision 4a, paragraph (a). Violation: For one staff person whose record was reviewed (SP1), the license holder did not complete orientation to individual service recipient needs as required.
The license holder did not complete orientation to individual recipient needs to SP1 in the following areas: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan to achieve and demonstrate an understanding of the person and a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure that SP1 has received the orientation listed above. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota statutes, section 245D.09, subdivision 4a, paragraph (d). Violation: For three staff persons whose records were reviewed (SP1-SP3) the license holder did not provide instruction on medication setup, assistance, or administration procedures as required. The license holder did not incorporate an observed skill assessment of SP1-SP3 during medication administration training to ensure SP1-SP3 demonstrated the ability to safely and correctly follow medication procedures. Repeat Violation: In a licensing action that DHS issued on July 18, 2024, and a correction order that DHS issued on February 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1-SP3 with medication administration training that incorporates an observed skill assessment to ensure SP1-SP3 demonstrate the ability to safely and correctly follow medication procedures; · audit all staff training to ensure the above mentioned training that incorporates an observed skill assessment has been provided and provide the training to any staff person who has not received the training and completed an observed skill assessment; · maintain documentation of the completed training and observed skills assessment in the staff’s personnel records and results of the audit in your program records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP2 and SP4) the license holder did not complete annual training as required. a. The license holder did not provide annual training to SP1 on the license holder’s program abuse prevention plan in 2023 and 2024. The license holder provided this training to SP1 on March 20, 2025. b. The license holder did not provide SP2 with annual training on data privacy requirements according to 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 in 2024. c. The license holder did not provide SP4 with annual training on the following topics in 2025: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; and · principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 and SP4 with the above mentioned trainings. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not ensure program coordination and evaluation as required. a. The license holder did not ensure that the designated coordinator (SP5) provided supervision, support, and evaluation of the services provided. See citations 1 through 16 for the designated coordinator’s failure to: · oversee the license holder's responsibilities assigned in the person's support plan and the support plan addendum; and · 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. b. The license holder did not ensure that the designated manager (SP6) provided program management and oversight of the services provided. Corrective action was ordered in a correction order dated February 18, 2025. The license holder did not ensure corrective action was completed as ordered as evidenced in citations 2, 3, 4, and 7. See citations 1 through 16 for the designated manager’s failure to: · maintain 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 (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · 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 is taken when ordered by the commissioner. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the staff person(s) identified as designated coordinator and designated manager for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and · maintain a signed document that the designated coordinator(s) and designated manager(s) have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in these subdivisions. 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. Nicole Riley, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-3657
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