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October 7, 2025 Mohamed Kodah MAK Healthcare Inc 1013 Cliff Road East Suite 102-200 Burnsville, MN 55337 License Number: 1091753 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Mohamed Kodah: On September 22, 2025, a licensing review of MAK Healthcare Inc, located at 1013 CLIFF Road East Burnsville, 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 two persons whose record was reviewed (P1), the license holder did not provide a written notice that identified service recipient rights as required. The license holder initiated a new service with P1 on September 1, 2024. The license holder did not provide a written notice that identified the service recipient rights and explanation of those rights within five working days of service initiation. At the time of the licensing review, this had not yet been completed. Corrective Action Ordered: Within 30 days of receiving this notice, you must: · provide P1 or P1’s legal representative with a written notice that identifies the service recipient rights and an explanation of those rights; and · maintain documentation of the receipt of the service recipient rights and an explanation of those rights according to Minnesota Statues 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (c). Violation: For one person whose record was reviewed (P1), the license holder did not complete service planning for basic support services as required. The license holder provided individualized home supports and night supervision to P1. The license holder did not include in P1’s support plan addendum how night supervision would be provided, including how, when and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services for night supervision. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1’s preliminary support plan addendum to document the information detailed above; and · provide orientation on the updates to P1’s support plan addendum to all staff that provide direct support to P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain a service recipient record as required. a. The license holder did not maintain a signed statement for P1 authorizing the license holder to act in a medical emergency when P1’s legal representative cannot be reached or is delayed in arriving. b. The license holder did not maintain progress or daily log notes for P1 and P2 that were recorded by the program. Corrective Action Ordered: Within 15 days of receiving this order, you must: · maintain a signed statement from P1’s legal representative authorizing you to act in a medical emergency; and · begin maintaining progress or daily log notes for P1 and P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, Section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not provide copies of the policies and procedures as required. The license holder did not inform P1’s case manager of the following policies and procedures and did not provide copies within five working days of service initiation: · grievance policy and procedures; · service suspension and termination policy and procedure; and · emergency use of manual restraints policy and procedure. The license holder initiated services for P1 on June 24, 2024. The license holder provided copies to P1’s case manager on July 8, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of five staff persons whose record were reviewed (SP2 and SP3), the license holder did not provide orientation to the program as required. a. The license holder did not provide SP2 with training on the principles of person-centered service planning and delivery as identified in section 245D, subdivision 1a, and how they apply to direct support service provided by staff persons within 60 days of hire. The license holder hired SP2 in November 2022 and provided SP2 with this training in December 2023. b. The license holder did not provide SP3 with the following trainings within 60 days of hire: · the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures, including: o grievance and complaint procedures; o service suspension and termination policy and procedure; and o emergency use of manual restraint; · data privacy requirements according to sections 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 section 245D.04; · sections 245A.65, 245A.66 and 626.557 and chapter 260E governing maltreatment reporting and services planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support services 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 restraint, 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; · basic first aide; and · strategies to minimize sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities. The license holder hired SP3 in May 2023 and provided SP3 with these trainings in February 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide orientation to individual service recipient needs as required. Prior to SP3 having unsupervised direct contact with a person served by the program, the license holder did not ensure SP3 reviewed and received instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, 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. The license holder hired SP3 in May 2023 and maintained documentation in SP3’s personnel file that this training was completed in August 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training 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. a. The license holder did not provide SP2 with annual training on topics identified in subdivision 4, clauses (3) to (11) in 2024. The license holder provided SP2 with annual training in November 2023 and December 2024. b. The license holder did not provide SP3 with annual training on topics identified in subdivision 4, clauses (3) to (11) in 2025. The license holder provided SP3 with annual training in May 2024 and June 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not maintain personnel records as required. The license holder did not ensure SP1-SP3’s training record documented the date training was completed, the number of hours per subject area, and the name of the training or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: For one staff person whose record was reviewed (SP5), the license holder did not provide coordination and evaluation of individual service delivery as required. The license holder did not maintain documentation that SP5 was competent to perform the duties of the designated coordinator as identified in section 245D.081, subdivision 2, paragraph (a). Corrective Action Ordered: Within 30 days of receiving this order you must: · submit documentation of SP5 or a new person(s) you have designated and have ensured is competent to perform the duties of the designated coordinator as required in this section; and · submit a signed acknowledgement that the designated person has reviewed and understands the responsibilities of a designated coordinator according to 245D.081, subdivision 2, paragraph (a). 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 64953 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. Coty Aust, HCBS Licensor Licensing Division Office of Inspector General 651-431-4605
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