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September 3, 2025 Michael Raymond Wentz, Authorized Agent Michael Raymond Wentz 1322 13th Avenue East Hibbing, Minnesota, 55746-1220 License Number: 1074515 (245D – HCBS) CORRECTION ORDER Dear Michael Raymond Wentz: On August 5, 2025, a licensing review of Michael Raymond Wentz, located at 1322 13th Avenue East, Hibbing, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one of one person whose record was reviewed (P1), the license holder did not establish and enforce individual abuse prevention plans (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. The license holder did not include statements of measures that included specific actions the program would take to minimize the identified risks of abuse within the scope of the licensed service in P1’s IAPP. Additionally, the license holder did not review P1’s IAPP annually in 2022, 2023, and 2024 with P1 and P1’s interdisciplinary team. Corrective Action Ordered: Within 30 days of receiving this order, you must: · revise P1’s IAPP to include specific actions the program would take to minimize the identified risks of abuse within the scope of the licensed services; · review P1’s revised IAPP with their interdisciplinary team and maintain documentation of this review in their record; and · provide training on the updates to P1’s IAPP to all staff that provide direct support to P1. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide service recipient rights as required. The license holder did not provide P1 with a written notice that identified the service recipient rights annually in 2022, 2023, and 2024. Additionally, the license holder did not provide the service recipient rights that includes: · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with the service recipient rights; and · maintain documentation of P1’s receipt of copy and an explanation of the rights in P1’s record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments as required.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete the required assessments for P1 that produce information that describes P1’s overall strengths, functional skills, and abilities; · review the assessments with P1 and P1’s case manager and members of the support team; and · document the review in P1’s support plan addendum. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not develop service outcomes and supports as required. The license holder did not develop the following supports and methods to be implemented to support P1 to accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being: • the methods or actions that would be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person's communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop supports and methods for P1’s desired outcomes including the information detailed above; · submit to P1 and P1’s case manager for approval; · provide training to P1’s documented supports and methods to all staff who provide direct support services to P1; and · implement the supports and methods for P1’s desired outcomes and track data related to their outcomes. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5 Violation: For one person whose record was reviewed (P1), the license holder did not complete services planning and review as required. The license holder did not meet with P1 and P1’s case manager, and other people as identified by P1 to participate in service plan review meetings, at least once per year in 2022, 2023 and 2024, to determine: · whether changes were needed to the service plan based on the assessment information, or other information provided by the support team or expanded support team; · how technology might be used to meet the P1’s desired 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: Within 30 days of receiving this order, you must: · meet with P1 and P1’s case manager and members of the support team and determine if changes are needed in P1’s support plan addendum; · discuss with P1 and P1’s case manager and members of the support team and determine how technology might be used to meet P1’s desired outcomes and options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider; and · document the summary of this discussion that includes: o a statement regarding any decision that is made regarding the use of technology; and; o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes for P1. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, 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 the identified positive support strategies with P1 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate the identified positive support strategies with P1 and document the evaluation in P1’s support plan addendums; and · based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation the license holder’s program abuse prevention plan (PAPP) as required. a. The license holder did not provide SP2 with an orientation to the license holder’s PAPP annually as required. b. The license holder did not provide SP3 with an orientation to the license holder’s PAPP within 72 hours of first providing direct contact services as defined in section 245C.02, subdivision 11 as required. Corrective Action Ordered: Within 30 days of receiving this order, you must provide orientation to the license holder’s PAPP to SP2 and SP3. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide orientation training as required. a. The license holder did not to provide SP3 with the following trainings within 60 days of hire: · the 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: o consumer grievance and compliant procedures; o consumer temporary service suspension and service termination; o emergency use of manual restraint; o health service coordination and care; o service admission; o emergency response, reporting, and reviewing; and o incident response, reporting, and reviewing; and · 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 and chapter 260E governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · 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 or successor provisions, 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, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; and · basic first aid. b. The license holder did not provide the following orientation to 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 receiving this order, you must: · provide SP3 with the above-mentioned orientation trainings; and · maintain documentation of when SP3 receives the training, including: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual staff training as required. The license holder did not provide SP1 and SP2 with annual training in 2022, 2023, and 2024 as required in the following areas: · 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; · 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; · the 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; · 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; 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 train SP1 and SP2 on the above-mentioned trainings. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one staff person whose record was reviewed (SP3), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP3 that included the date of the employee’s first supervised and unsupervised direct contact with a person served by the program. Additionally, the license holder did not maintain a personnel record for SP3 to document and verify staff qualifications, orientation, and training. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: The license holder did not establish policies and procedures related to alleged or suspected maltreatment of vulnerable adults as required. The license holder did not establish policies and procedures related to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults that identified: · the primary and secondary person or position to whom internal reports may be made and the primary and secondary person or position responsible for forwarding internal reports to the common entry point; and · the primary and secondary person or position who will ensure that, when required, internal reviews are completed. Corrective Action Ordered: Within 30 days of receipt of this order, you must establish policies and procedures related to alleged or suspected maltreatment of vulnerable adults that includes the above requirements. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.10, subdivision 2. Violation: The license holder did not establish policies and procedures related to grievances as required. The license holder did not establish policies and procedure related to grievances that provided the name, address and telephone number of the highest level of authority. Corrective Action Ordered: Within 30 days of receipt of this order, you must establish policies and procedures related to grievances that provides the name, address and telephone number of the highest level of authority. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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. Jolene Reinke, HCBS Licensor Licensing Division Office of Inspector General 651-431-5928
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