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September 26, 2025 Akinbowale John Barbington, Authorized Agent New Hope Living & Nursing Services 6901 78 Avenue North, Suite 101 Brooklyn Park, Minnesota 55445-2720 License Number: 1070370 (245D – HCBS) 1110149 (Community Residential Setting)
Investigation Number: 202503994 CORRECTION ORDER Dear Akinbowale John Barbington: On August 12, 2025, through August 14, 2025, a licensing review and licensing investigation of New Hope Living & Nursing Services, located at 6901 78 Avenue North, Suite 101, Brooklyn Park, 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 and licensing investigation, 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.081, subdivisions 2 and 3. Violation: The license holder did not ensure the program management, evaluation, and oversight of the services provided by the license holder as required. a. The license holder did not ensure the staff persons the license holder identified as designated coordinators provided coordination of service delivery and evaluation for each person served by the program that included: · oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service 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 coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder did not ensure the staff person the license holder identified as the designated manager provided program management and oversight of the services provided by the license holder that included: · 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; · 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; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations 2 through 16 for evidence of the designated coordinators and the designated manager’s lack of program coordination, management, and oversight. Corrective Action Ordered: Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one of nine persons whose records were reviewed (P1), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required. The license holder did not provide an orientation to the program abuse prevention plan (PAPP) to P1 within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with an orientation to the PAPP and notify P1’s legal representative of the orientation; and · maintain documentation of this orientation in P1’s support plan addendum. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivisions 2 and 3. Violation: For three persons whose records were reviewed (P2, P4, and P9), the license holder did not ensure the exercise and protection of the person’s rights in the services provided as required. a. P4 and P9 lived in a community residential setting (CRS, license number 1110149). During a walk-through of the CRS, DHS licensors observed a strong odor throughout the site, and cobwebs and dirty floors in the basement. The license holder did not ensure the exercise and protection of the following rights for P4 and P9: · receive services in a clean and safe environment when the license holder is the owner, lessor or tenant of the service site; and · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, or insects. b. The license holder did not ensure the exercise and protection of P2’s right to associate with persons of P2’s choice when the license holder only allowed P2 to visit with other persons when the visit was pre-approved by P2’s legal representative. c. The license holder did not ensure the exercise and protection of P4’s right to engage in chosen activities and right to access personal possessions. The license holder limited the amount of time P4 could use their personal iPad and removed their iPad two hours before P4 went to bed. Once the license holder removed the iPad, the license holder did not allow P4 to access their iPad for the rest of the day. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must restore the above protection related rights to P2, P4, and P9. Within 30 days of receiving this order, you must develop a corrective action plan that includes the following: · a summary of the measures you have taken to restore the rights identified above to P2, P4, and P9; · a detailed plan of how your program will maintain compliance on an ongoing basis with ensuring the exercise and protection of the rights mentioned above for all persons who reside in your program’s CRS sites; and · maintain the summary and your detailed plan in your program’s records. 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.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P4), the license holder did not review the need for the rights restriction as required. The license holder implemented a rights restriction for P4 on April 6, 2023. The license holder did not review the need for the restriction based on the conditions for ending the restriction semiannually from the date of initial approval. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receipt of this order, you must review the need for P4’s rights restriction with P4, P4’s legal representative and case manager. You must document this review and maintain the 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. 5. Citation: Minnesota Statutes, section 245D.06, subdivision 1, and section 245D.11, subdivision 2. Violation: For one person whose record was reviewed (P4), the license holder did not maintain information about, and report incidents as required. a. P4 was involved in incidents on May 1, 2025, and May 10, 2025, that resulted in the license holder implementing emergency use of manual restraints. The license holder did not verbally report the emergency use of manual restraint within 24 hours of occurrence to P4’s legal representative and case manager. b. The license holder did not enforce the program’s written policy and procedure related to the reporting and review of incidents for incidents that involved P4 on May 1, 2025, and May 10, 2025. The license holder did not complete an incident report within 24 hours after the incident occurred that included the following: · the name of the person or persons involved in the incident; · the date, time, and location of the incident; · a description of the incident; · a description of the response to the incident and whether a person’s support plan addendum or program policies and procedures were implemented as applicable; · the name of the staff person or persons who responded to the incident; and · the results of the review of the incident. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · report the emergency use of manual restraints on the dates identified above to P4’s legal representative and case manager; · maintain documentation of the notifications in P4’s support plan addendum; and · complete reports for the incidents identified above in letter b. You must include the bulleted information in your report. 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.05, subdivision 1, paragraphs (a) and (b). Violation: For four persons whose records were reviewed (P1, P4, P5, and P7), the license holder did not meet persons health needs as required a. The license holder was assigned the responsibility of meeting P7’s health needs including monitoring health conditions according to written instructions form a licensed health professional. The license holder did not meet P7’s health needs when the license holder did not monitor P7’s health condition for over 17 days and P7 was hospitalized as a result. b. The license holder was assigned the responsibility of meeting P1’s, P4’s, and P5’s health needs in P1’s, P4’s, and P5’s support plans and support plan addendums. P1, P4, and P5 were prescribed PRN psychotropic medications. The license holder did not maintain documentation on how P1’s, P4’s, and P5’s health needs would be met in P1’s, P4’s, and P5’s support plan addendums, including a description of the procedures the license holder would follow in order to administer the person’s psychotropic PRN medication. c. The license holder was responsible for monitoring P1’s chronic health condition and administering a PRN medication for the health condition. The license holder did not maintain documentation on how the P1’s health needs would be met, including a description of the procedures the license holder would follow in order to monitor health conditions according to written instructions from a licensed health professional. d. The license holder was responsible for monitoring P7’s chronic constipation and administering a PRN medication for constipation. The license holder did not maintain documentation on how P7’s health needs would be met, including a description of the procedures the license holder would follow in order to monitor health conditions according to written instructions from a licensed health professional. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction Order issued on May 16, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document the above information in P1’s, P4’s, P5’s, and P7’s support plan addendums; · provide staff persons who provide direct care services to P1, P4, P5, and P7 with a training on the updated information; and · maintain documentation of this training in the staff persons’ personnel record. Compliance with this subdivision will be monitored at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P7), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for medication administration for P4. The license holder documented multiple medication errors between May 14, 2025, and July 20, 2025, where P4 did not receive several daily prescribed medications due to the program not having the medication available. The license holder did not implement medication administration procedures to ensure P4 took medications and treatments as prescribed when the license holder did not ensure medication refill requests were communicated in a timely manner. b. The license holder was assigned responsibility for medication administration for P7. The license holder did not accurately document information from the prescription label for P7’s PRN medication in P7’s medication administration record (MAR). Additionally, the license holder did not implement medication administration procedures to ensure P7 took PRN medications for constipation as prescribed between July 25, 2025 and August 13, 2025. c. The license holder maintained documentation in P7’s MAR on July 7, 2025, that one of P7’s medications was not administered on July 8, 2025, and a different medication was not administered due to being on hold. Licensors determined that P7’s medications were not on hold, but that the license holder had not refilled the prescription with P7’s pharmacy. The license holder did not implement medication administration procedures to ensure P7 took medications as prescribed when the license holder did not request refills for P7’s medications in a timely manner. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction order issued on May 16, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P7’s MAR to ensure the information on the current prescription label or the prescriber’s current order is documented accurately; · develop and implement a plan across your program to ensure medication refills are requested in a timely manner to ensure persons receive medications as prescribed when you are assigned the responsibility of medication administration; · maintain documentation of the plan in your program’s records; · train all staff who are responsible for administering medications on your plan and how to implement it; and · maintain documentation of the training you provide to staff persons in the staff persons’ personnel records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For two people whose records were reviewed (P4 and P7), the license holder did not report medication and treatment issues as required. a. The license holder documented multiple medication errors between May 14, 2025, and July 20, 2025, when P4 did not receive several daily prescribed medications due to not having the medication available. The license holder did not report medication errors to P4’s case manager as they occurred. b. The license holder documented medication errors on July 7, 2025, and July 8, 2025, when P7 did not receive a daily prescribed medication due to the medications not being refilled by the pharmacy. The license holder did not report medication errors to P7’s legal representative or case manager as they occurred. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction Order issued May 16, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of this order, you must: · review P4’s and P7’s MARs from April to current to ensure the information maintained in the MAR is current and to identify medication administration errors; · report any medications errors found in P4’s and P7’s MARs to their legal representatives and case managers; and · maintain documentation of the notifications regarding the medication errors in P4’s and P7’s records. 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.051, subdivision 1. Violation: For two persons whose record was reviewed (P1 and P7), the license holder did not monitor the use of the psychotropic medications 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 responsibility for administering P1’s and P7’s psychotropic medications. The license holder did not maintain documentation of a description of the target symptoms for each psychotropic medication prescribed to P1 and P7 in the person’s support plan addendum. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction Order issued on May 16, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain documentation of a description of the target symptoms for each psychotropic medication prescribed to P1 and P7 in their support plan addendums; · audit the records of all persons your program is assigned the responsibility for medication administration to ensure each person’s support plan addendum includes a description of target symptoms for each psychotropic medication prescribed to the person; · for any person who does not have target symptoms documented for each psychotropic medication, you must document the target symptoms in the person’s support plan addendum; and · maintain the audit results in your program’s records. 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.061. Violation: For one person whose record was reviewed (P4), the license holder did not ensure that emergency use of manual restraints complied with the requirements of this chapter. P4 was involved in an incident on May 1, 2025, and May 10, 2025, that resulted in the license holder implementing the use of a manual restraint. The license holder did not complete the following: • report in writing to the designated coordinator about the emergency use within three calendar days after an emergency use of manual restraint; • complete and document an internal review within five working days of the emergency use of manual restraint; • evaluate in the internal review whether the person’s service and support strategies developed according to section 245D.07 and 245D.071 need to be revised; • 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; and • submit the following to the Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities within five working days of the expanded support team review: o the report required under subdivision 5; o the internal review and corrective action plan required under subdivision 6; and o the summary of the expanded support team review required under subdivision 7. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must complete the above mentioned items for P4 and maintain documentation of what was completed in P4’s service recipient record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P8), 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 maintained a document in P8’s record regarding Disability Waiver Rate System exceptions that indicated the license holder was responsible for ensuring P8 lived alone. On July 28, 2025, the license holder moved P8 to another service site where P8 had a roommate. The license holder did not provide services as assigned in the support plan when the license holder stated the criterion of P8 living alone was not met. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must provide services as assigned in the support plan. On an ongoing basis, you maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For three persons whose records were reviewed (P2, P4, and P8), the license holder did not provide services in response to the person’s identified needs, interests, and preferences as required. a. The license holder did not provide services in response to P2’s identified interests, and preferences when the license holder documented the name of another service recipient in P2’s outcome documentation. DHS licensors could not determine if this outcome was developed for P2.
b. P8’s individual abuse prevention plan developed by the license holder documented P8 had one hour of alone time at home. Information maintained elsewhere in P8’s support plan addendum developed by the license holder documented P8 had two hours of alone time at home. The license holder did not provide services in response to P8’s identified needs when the license holder maintained conflicting documentation about P8’s supervision needs. c. P4’s support plan identified that P4 wanted to start attending a day program. The license holder did not use information consistent with the principals of person-centered service planning and delivery, that used information to identify outcomes P4 desired, when the license holder developed outcomes for P4 about walking and community activities. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction Order issued on April 25, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · review and revise P2’s outcome to ensure P2’s outcome is developed for P2; · review and revise P8’s support plan addendum, and individual abuse prevention plan to reflect the number of hours of alone time P8 has at home; · meet with P4, P4’s legal representative, P4’s case manager, and other members of P4’s interdisciplinary team to discuss options for starting at a day program. You must maintain documentation of this meeting in P4’s support plan addendum and implement the preferences of P4 based off this meeting; and · review P4’s support plan addendum to identify what is important to P4 as well as what is important for P4, including preferences for when, how, and by whom direct support service is provided, and use this information to identify and develop outcomes P4 desires. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P4), the license holder did not implement service outcomes and supports as required. The license holder did not implement P4’s supports and methods to accomplish outcomes when the license holder did not collect data on P4’s outcomes from June 2025 through August 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must begin implementing P4’s supports and methods, including collecting data. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required with this subdivision.
14. Citation: Minnesota Rules 9544.0060, subpart 2, paragraph (f). Violation: For one person whose record was reviewed (P7), the license holder did not restrict the use of prohibited procedures. Minnesota Rules 9544.0060, subpart 2 lists specific prohibited actions or procedures that include the action of denying or restricting a person's access to equipment and devices, such as wheelchairs, that facilitate the person's functioning. When the temporary removal of the equipment or device is necessary to prevent injury to the person or others or serious damage to the equipment or device, the equipment or device must be returned to the person as soon as imminent risk of injury or serious damage has passed. The license holder was responsible for assisting P7 with mobility and transferring and P7 used a wheelchair. P7 would attempt to stand on furniture and was at risk of falling. The license holder placed P7 on the floor when this occurred to prevent P7 from injuring themselves. The license holder used a prohibited procedure when the license holder denied P7’s access to P7’s wheelchair and kept P7 on the ground after the risk of injury had passed, for up to three hours at a time, on several occasions. Corrective Action Ordered: Immediately upon receiving this order, you must stop using prohibited procedures in your program. Within 30 days of receiving this order, you must: · train all staff persons on what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · train all staff persons on 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; · train all staff persons on de-escalation methods, positive support strategies, and how to avoid power struggles; · document the training in all staff persons’ personnel records; and · designate a designated coordinator, and/or the designated manager to review daily progress notes for all persons receiving services from July 1, 2025, to September 1, 2025, to identify any prohibited procedures used by the program. If any prohibited procedures were used by the program, you must utilize your program’s policies and procedures related to suspected or alleged maltreatment to determine if a maltreatment report must be made. 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.095, subdivision 5. Violation: For three of five staff persons whose records were reviewed (SP2, SP4 and SP5), the license holder did not maintain personnel records as required. a. The license holder did not document the number of hours per subject area for SP2 and SP4’s trainings. b. The license holder did not maintain a personnel record for SP5 that included training documentation, including the number of hours per subject area. Additionally, the license holder did not maintain a copy of SP5’s job description in SP5’s personnel record. Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 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 with this subdivision. 16. Citation: Minnesota Statutes, section 245D.11, subdivision 2. Violation: For three persons whose records were reviewed (P1, P5, and P7), the license holder did not enforce and maintain policies and procedures for safe medication administration as required. a. The license holder’s medication administration policy stated, “staff will, beginning with the highest number, push the correct dose [from the bubble pack] into a medication cup, and write the date and their initials on the card next to the dose popped out.” The license holder did not to enforce this policy when the license holder did not document on the bubble packs when staff administered medication to P1 and P5. b. The license holder’s medication administration policy stated, “The manager or other assigned staff person will be responsible for checking medication supply routinely to ensure adequate amount for administration.” The license holder did not enforce the program’s policy when the license holder did not check P7’s medication supply routinely to ensure an adequate amount for administration (see citation 7). Repeat Violation: In an Order of Conditional License that DHS issued on April 23, 2025, and a Correction Order issued May 16, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · re-train all staff persons who administer medication on your program’s safe medication policy; · maintain documentation of this training in the staff persons’ personnel records; · develop a detailed plan on how the manager or assigned staff person will ensure that the medication supply for all service recipients will be routinely checked to ensure adequate amounts for administration; · maintain documentation of this plan in your program’s records; and · train the manager or assigned staff person on their responsibilities regarding routine checks of medications. Compliance with this subdivision will be monitored 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. Lacey Walsvik, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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