Minnesota

October 7, 2025

Michelle O’Toole, Authorized Agent

Diversified Lifestyles, Inc.

1111 6th ST SE

Willmar, MN 56201-4637

License Numbers: 1069582 (245D-Home and Community-Based Services)

Investigation Report Number: 202500642

CORRECTION ORDER AND

NONCOMPLIANCE WITH TERMS OF A CONDITIONAL LICENSE

Dear Michelle O’Toole:

On May 3, 2024, the Commissioner of the Department of Human Services (DHS) issued an Order of Conditional License to Diversified Lifestyles Inc., located at 1111 6th Street SE, Willmar, Minnesota.

On August 19 – 21, 2025, a licensing review of Diversified Lifestyles, Inc., was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services (HCBS) to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D and the terms of the Order of Conditional License issued on May 3, 2024. In addition, a licensing complaint investigation was completed regarding report number 202500642. As a result of this licensing review and the licensing complaint investigation, a Correction Order and Noncompliance with the Terms of a Conditional License is being issued.

A. Reason for Correction Order and Noncompliance with the terms of Conditional 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 and maltreatment investigations. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Program Coordination and Oversight

1. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Violation: The license holder did not meet the requirements for program coordination, evaluation and oversight.

a. The license holder identified SP4 as the designated coordinator. The license holder did not ensure that the staff person the license holder identified as the designated coordinator provided the supervision, support, and evaluation of activities that include:

· 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 outcomes according to the requirements in section 245D.07;

· instructions and assistance to direct support staff implementing the support plan and the service outcomes, including the failure to have an established process in which the designated coordinator determines the competency of the person that has been delegated the responsibility to directly observe the service delivery activities to assess staff competency; and

· evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired 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.

The lack of program coordination and oversight of the services provided is evidenced in citations 2 – 16.

b. The license holder identified SP4 as the designated manager. The license holder did not ensure that the staff person the license holder identified as the designated manager performed the required program management and oversight of the services provided by the license holder including:

· maintaining a current understating of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, identified in in section 256B.04, subdivision 21, paragraph (g);

· ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2;

· ensuring staff competency requirements were met according to the requirements in section 245D.09, subdivision 3, including ensure periodic performance evaluations of direct support staff’s ability to perform the job functions based on direct observations are completed by the license holder;

· ensuring corrective action was taken when ordered by the commissioner and that the terms and conditions of the license were met; and

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

The lack of program management and oversight of the services provided is evidenced in citations 2 – 16.

Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, and a Correction Order that DHS issued on April 18, 2025, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receiving this order, you must complete all corrective action as ordered in this order. You must ensure that the program’s designated coordinator and designated manager provide program coordination, evaluation, and oversight as required. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision

Service Recipient Violations

2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: For two of five people whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required.

a. The license holder assessed P1 as susceptible to sexual abuse. The license holder did not include a statement of specific measures that would be taken to minimize the risk of abuse in this assessed area.

b. The license holder assessed P2 as susceptible to abuse in multiple areas. The license holder did not include a statement of specific measures that would be taken to minimize the risk of abuse in each area assessed.

Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P1’s and P2’s IAPPs to include the above-mentioned information. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.06, subdivision 4.

Violation: For three people whose records were reviewed (P2, P4 and P5), the license holder did not meet the requirements for safeguarding and handling a person’s funds and property as required.

a. The license holder did not obtain written authorization from P2’s legal representative and P4’s case manager for the safekeeping of funds and property annually as required. Additionally, the license holder did not survey the preferences of P2’s and P4’s legal representative and case managers for frequency of receiving a statements that itemized receipts and disbursements of funds or other property.

b. The license holder was responsible for the safekeeping of P5’s funds. P5’s financial authorization dated August 29, 2024, documented P5’s legal representative requested semiannual itemized financial statements that itemized the receipts and disbursements of funds and other property. The license holder did not provide these financial statements semiannually to P5’s legal representative.

Corrective Action Ordered: Within 30 days of receipt of this order, you must:

· obtain written authorization from P2’s legal representative and P4’s case manager to assist with the safekeeping of funds and property;

· survey the preferences of P2’s and P4’s legal representatives and case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds or other property; and

· provide P5’s legal representative with financial statements as listed above.

Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.061, subdivision 8.

Violation: For one person whose record was reviewed (P1), the license holder did not report the emergency use of manual restraint as required.

During a licensing review conducted on September 10-12, 2024, DHS licensors observed documentation indicating P1 was involved in an incident that resulted in an emergency use of manual restraint on January 19, 2024. In the correction order dated December 6, 2024, the license holder was ordered to submit the following to the Department of Human Services, and the Office of the Ombudsman for Mental Health and Developmental Disabilities, as required under section 245.94, subdivision 2a:

· the report required under subdivision 5;

· the internal review and the corrective action plan required under subdivision 6; and

· the summary of the expanded support team review required under subdivision 7.

P1’s record was again reviewed during a licensing review conducted on March 18 – 20, 2025. DHS licensors determined this report was not completed as ordered. The license holder was ordered again to complete this report in the correction order dated April 18, 2025. During this licensing review, the license holder indicated this report was completed. DHS licensors discovered this report has not been completed to DHS via online behavioral intervention report form.

Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, and a Correction Order that DHS issued on April 18, 2025, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 10 days of receiving this order, you must submit the above-mentioned information for P1 to the Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities, as required under section 245.94, subdivision 2a. You must submit a copy of the report to your licensor. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not provide services in response to desired outcomes as required.

a. The license holder did not collect the required data for P4’s outcome. At the time of the review, there had been no data collection on P4’s outcome since May 1, 2025. The license holder did not implement the supports and methods to support P4.

b. P5’s support plan addendum documented that staff would collect data on P5’s outcome as follows: a (I) if P5 followed the steps independently, a (V) if P5 required verbal prompts and (R) if P5 refused to participate in the outcome. The data tracking staff completed for the months of April 2025 to August 2025 only had (+) or (-). The license holder did not implement the supports and methods to support P5 and accomplish outcomes, including how data would be collected.

Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, and a Correction Order that DHS issued on April 18, 2025, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 60 days of receipt of this order, you must implement P4’s and P5’s outcome as written. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.071, subdivision 3.

Violation: For one person whose record was reviewed (P1) the license holder did not complete assessments as required.

The license holder did not complete assessments that produced information about the P1 that described their overall strengths, functional skills and abilities and behaviors or symptoms.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· complete an assessment of P1 based on their status within the last 12 months that includes the areas outlined above; and

· include the person’s strengths, functional skills and abilities, and behaviors or symptoms in the completed assessment.

Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not review and evaluate service plans as required.

The license holder did not discuss with P1 and P2, and members of their support teams about how technology might be used to meet P1’s and P2’s desired outcomes at least once per year.

Corrective Action Ordered: Within 30 days of receiving this order, you must discuss with P1 and P1’s support team about how technology might be used to meet their desired outcomes. A summary of this discussion and a statement regarding any decision made related to the use of technology including a description of any further research that must be completed before a decision can be made must be included in the support plan addendum as required. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g).

Violation: For two people whose records were reviewed (P4 and P5), the license holder did complete progress reports as required.

The license holder established outcomes for P4 and P5. The progress report did not accurately reflect the documented data collected on P4’s and P5’s goal statistical sheet.

Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receipt of this order, you must begin collecting data for P4’s and P5’s data as written in their outcomes. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Rules Part 9544.0030, subpart 1.

Violation: For two people whose records were reviewed (P2 and P5), the license holder did not evaluate positive support strategies as required.

a. The license holder used another service recipient’s positive support evaluation document with the service recipient’s name crossed out and P2’s name written in. The license holder did not implement and evaluate P2’s positive support strategies that used person-centered planning.

b. The license holder did not evaluate P5’s positive support strategies with P5 every six months.

Repeat Violation: In an Order of Conditional License dated May 3, 2024, and Correction Orders that DHS issued on December 6, 2024, and April 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 and evaluate P2’s and P5’s positive support strategies with P2 and P5. Compliance with this order with be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart.

Health Service Needs Violations

10. Citation: Minnesota Statutes, section 245D.05, subdivision 2.

Violation: For two persons whose records were reviewed (P6 and P7), the license holder assigned responsibility for medication administration in the support plan addendum. The license holder did not implement medication administration procedures as required.

a. The license holder did not document in P6’s medication administration record (MAR) a notation of a dose of medication being administered on the following dates:

· August 15, 2025;

· August 18, 2025; and

· August 19, 2025.

b. The license holder did not document in P7’s medication administration record (MAR) a notation of a dose of medication being administered on the following dates:

· August 15, 2025;

· August 17, 2025;

· August 18, 2025; and

· August 19, 2025.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a).

Violation: For three persons whose records were reviewed (P1, P2, and P5) the license holder did not ensure medication and treatment issues were reviewed and reported as required.

During the licensing review conducted March 18 – 20, 2025, DHS licensors reviewed medication administration record (MAR) reviews completed in March 2025 that were inaccurate. In a correction order dated April 18, 2025, the license holder was ordered to complete MAR reviews for the past six months for all persons served in the program. At the time of the review on August 19 – 21, 2025, the license holder had not completed these MAR reviews for P1, P2 and P5.

Corrective Action Ordered: Within 30 days of receipt of this order, you must complete the corrective action that was ordered in the Correction Order dated April 18, 2025. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.051, subdivision 1.

Violation: For three of five persons whose records were reviewed (P1, P3, and P5), the license holder did not meet the condition of psychotropic medication administration as required.

a. The license holder was assigned responsibility for monitoring and measuring the target symptoms to be alleviated by psychotropic medications for P1. The license holder did not:

· document the monitoring and measuring of the target symptoms;

· collect and report on medication and symptom related data as instructed by the prescriber; and

· provide monitoring data to the expanded support team for review semi-annually.

b. The license holder did not maintain documentation for P3 that included a description of the target symptoms that each psychotropic medication was to alleviate.

c. The license holder did not document a description of the target symptoms that P5’s psychotropic medications were to alleviate.

In addition, the license holder was assigned responsibility for monitoring and measuring the target symptoms to be alleviated by psychotropic medications for P5. The license holder did not:

· document the monitoring and measuring of the target symptoms;

· collect and report on medication and symptom related data as instructed by the prescriber; and

· provide monitoring data to the expanded support team for review semi-annually.

Corrective Action Ordered: Within 30 days of receipt of this order, you must begin documenting and collecting data on P1’s and P5’s target symptoms as listed above, and you must provide monitoring data to the expanded support team as listed above. You must maintain documentation in P3’s and P5’s addendum that includes a description of the target symptoms that each psychotropic medication is prescribed to alleviate. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

Staff Violations

13. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For one of three staff persons whose record was reviewed (SP1), the license holder did not provide orientation training as required.

The license holder failed to provide SP1 with basic first aid training within 60 days of hire.

Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP1 with basic first aid training. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute.

14. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide annual training as required.

The license holder did not provide basic first aid training to SP2 in 2024. At the time of the this review, the training had not been completed in 2025.

Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP2 with basic first aid training. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

Record Keeping Violations

15. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For one person whose record was reviewed (P2), the license holder did not maintain service recipient records as required.

The license holder did not maintain the following in P2’s record:

· a signed authorization from the person’s legal representative to administer medication or treatments; and

· documentation to show a signed statement authorizing the license holder to act in a medical emergency when the person’s legal representative cannot be reached or is delayed in arriving.

Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, and in a Correction Order that DHS issued on April 18, 2025, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the above-mentioned information in P2’s record. On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain personnel records as required.

The license holder did not document the number of hours per subject area in SP1’s training record.

Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, and a Correction Order DHS issued on April 18, 2025, you were previously found in violation of this same statute.

Corrective Action Ordered: Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

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 Diana Arnzen at 651-431-6638 as soon as possible.

Diana Arnzen, Senior Human Services Licensor

Licensing Division

Office of Inspector General

651-431-6638

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/