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October 9, 2025 CERTIFIED MAIL Samatar Dualeh, Authorized Agent Silver Mountain Home Health Care LLC 2722 Park Avenue, Suite 213 Minneapolis, Minnesota 55407-1009 License Number: 1081219 (245D - HCBS) ORDER OF CONDITIONAL LICENSE Dear Samatar Dualeh: The Department of Human Services (DHS) is placing Silver Mountain Home Health Care LLC’s license to provide Home and Community-Based Services (HCBS) on conditional status for two years, beginning October 9, 2025. This means you must meet certain conditions to maintain your license, detailed below. This order applies to all services licensed under Chapter 245D and the service sites detailed in the “Applicability of Conditional License” section below. This is based on your noncompliance with Home and Community-Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE Licensing Violations Determined on July 9-10, 2025. DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violation 1. Violation: The license holder did not ensure the designated coordinator and designated manager (SP10) provided program management and oversight of the services provided by the license holder as required. a. The license holder designated SP10 as one of the individuals responsible for overseeing the delivery and evaluation of services provided by the license holder. See citations 2 through 18 regarding the license holder’s inability to ensure SP10 met the following responsibilities: · oversight of the license holder’s responsibilities assigned in the persons support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in 245D.07; · 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; and · evaluation of the effectiveness of service delivery, methodologies, and process on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcome had been achieved according to the requirements in section 245D.07. b. The license holder designated SP10 as the designated manager. See citations 2 through 18 regarding the license holder’s inability to ensure SP10 met the following responsibilities: · maintaining 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 (g); · ensuring 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; · ensuring corrective action was taken when ordered by the commissioner in Correction Orders issued February 6, 2023, and April 25, 2023; and · evaluating the information identified in clauses (1) to (6) to develop, document and implement ongoing program improvements. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Repeat Violation: In a Correction Order that DHS issued on September 24, 2019, and April 25, 2023, you were previously found in violation of this same statute. Service Recipient Violations 2. Violation: For four of four persons whose records were reviewed (P1-P4), the license holder did not provide a written notice of the service recipient rights as required. The license holder did not provide P1 or P1’s legal representative, P2 or P2’s legal representative, P3 or P3’s legal representative, and P4 or P4’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. This had not yet been completed by the date of the licensing review. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on September 24, 2019, you were previously found in violation of this same statute. 3. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide services in compliance with the federal waiver plans as required. According to the Community Based Services Manual, individualized home supports with family training cannot be provided by relatives. Additionally, waivered services provided to individuals under the age of 18 cannot be provided by parents. The license holder did not follow the federal waiver plan when they allowed P1 and P2 to receive individualized home supports with family training services from a parent. Additionally, the license holder allowed a parent to provide night supervision services to P1, P2, P3, and P4. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1. 4. Violation: For one person whose record was reviewed (P2), the license holder did not provide person centered planning and service delivery as required. The license holder did not provide services in response to P2’s identified needs, interests, preferences, and desired outcomes as specified in the support plan addendum. The license holder included in P2’s support plan addendum that staff would keep notes each week on P2’s progress towards the identified outcome and the license holder would review the notes with P2’s support team monthly. The license holder did not maintain these notes or meet with the support team monthly regarding P2’s progress towards the outcome. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on February 6, 2023, and April 25, 2023, you were previously found in violation of this same statute. 5. Violation: For three persons whose records were reviewed, (P1, P2, and P4), the license holder did not complete service planning for basic support services as required. a. The license holder initiated two basic services with P1 on December 1, 2024. The license holder did not complete a preliminary support plan addendum based on the support plan for P1 within 15 calendar days of service initiation. At the time of the review, this had not yet been completed. b. The license holder provided two basic services to P2. The license holder did not document in the support plan addendum for P2 the services that 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. c. The license holder provided one basic service to P4. The license holder did not review and revise, as needed, P4’s preliminary support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of the services. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on September 24, 2019, and February 6, 2023, you were previously found in violation of this same statute. 6. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not complete assessments as required. a. The license holder did not complete assessments of P1 and P2 in the following areas before providing 45 days of service: · P1’s and P2’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P1’s and P2’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · P1’s and P2’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 welfare of the person or others. The license holder initiated services with P1 on December 1, 2024. At the time of the review, the required assessments had not been completed for P1. The license holder initiated services with P2 on September 8, 2023. The required assessments were completed on September 13, 2024. Additionally, the license holder did not provide the results of P2’s assessments to P2’s support team as part of a service plan review.
b. The license holder did not include any strengths, functional skills, or abilities as required when completing P3's assessments. Additionally, the license holder did not conduct assessments for P3 annually in 2025. The license holder conducted these assessments for P3 on April 20, 2024. At the time of the licensing review, the license holder had not conducted these assessments for P3 in 2025. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on February 6, 2023, and April 25, 2023, you were previously found in violation of this same statute. 7. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not develop service outcomes and supports as required.
a. The license holder did not hold an initial planning meeting with P1, P1’s legal representative, P1’s case manager, P2, P2’s legal representative and P2’s case manager before providing 45 days of services to determine the following: · the scope of the services to be provided to P1 and P2; · P1’s and P2’s desired outcomes and the supports necessary to accomplish P1’s and P2’s desired outcomes; · P1’s and P2’s preferences for how services and supports were provided, including how the provider would support P1 and P2 to have control of P1’s and P2’s schedule; · whether the current service setting was the most integrated service setting available and appropriate for P1 and P2; · 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; · opportunities to develop and strengthen personal relationships with other persons of P1’s and P2’s choice in the community; · how services must be coordinated across other providers licensed under this chapter serving P1 and P2 and members of the support team or expanded support team to ensure continuity of care and coordination of services for P1 and P2; and · how technology might be used to meet P1’s and P2’s desired outcomes. The license holder initiated services with P1 on December 1, 2024. At the time of the review, the initial planning meeting had not occurred. The license holder initiated services with P2 on September 8, 2023, and held an initial planning with P2’s legal representative on October 9, 2024. The license holder did not invite P2’s case manager to participate in the meeting and did not provide an update to P2’s case manager as to the results of the meeting. b. The license holder held P4’s initial planning meeting on January 22, 2025. The license holder did not: · invite P4’s case manager to participate in this meeting; · hold a discussion of how technology might be used to meet the P4's desired outcomes; and · include a summary of this discussion in P4’s support plan addendum that included a statement regarding any decision that was made regarding the use of technology and a description of any further research that needed to be completed before a decision regarding the use of technology could be made. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 6, 2023, you were previously found in violation of this same statute. 8. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not develop service outcomes and supports as required.
a. The license holder did not develop a service plan for P1 that documented the supports and methods to be implemented to support P1 with accomplishing outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and wellbeing including: · the methods or actions that would be used to support P1 and to accomplish services outcomes including any information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment and materials required; and o techniques that were consistent with P1’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. b. The license holder did not develop a service plan for P2 that documented the supports and methods to be implemented to support P2 including: · the measurable and observable criteria for identifying when the desired outcome had been achieved; and · the projected starting date for implementing the supports and methods. Additionally, the license holder did not submit to and obtain dated signatures from P2 or P2’s legal representative and P2’s case manager to document the completion and approval of the assessment and support plan addendum. c. The license holder did not develop a service plan for P3 that documented the supports and methods to be implemented to support P3 with accomplishing outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and wellbeing including: · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports; and · the names of the staff or position responsible for implementing the supports and methods. d. The license holder did not develop a service plan for P4 that documented the supports and methods to be implemented to support P4 with accomplishing outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and wellbeing including: · the methods or actions that would be used to support P4 and to accomplish services outcomes including any information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods; and · the names of the staff or position responsible for implementing the supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on February 6, 2023, and April 25, 2023, you were previously found in violation of this same statute. 9. Violation: For one person whose record was reviewed (P3), the license holder did not complete service plan review and evaluation as required. a. The license holder held service plan review and evaluation meetings for P3 in 2024 and 2025. The license holder did not include P3’s case manager at these meetings. The license holder did not give P3’s case manager the opportunity to participate in the ongoing review and development of the service plan and the methods used to support P3 and accomplish outcomes identified in subdivisions 3 and 4. b. The license holder did not summarize P3’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of P3’s progress review meeting in 2024. c. The license holder did not send P3’s support plan addendum to P3’s case manager within ten working days of the progress review meeting in 2024. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. 10. Violation: For one person whose record was reviewed (P2), the license holder did not maintain a service recipient record as required. The license holder did not protect P2’s service recipient record against loss, tampering, or unauthorized disclosure according to the requirements in sections 13.01 to 13.10 and 13.46. The license holder moved offices and stated that during the move, portions of P2’s record were lost. Additionally, the license holder did not maintain progress or daily log notes that were recorded by the program for P2. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. 11. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. a. The license holder did not inform and provide P1’s, P2’s, and P4’s case managers with the following policies and procedures affecting P1’s, P2’s, and P4’s rights within five days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy requirements. At the time of the review, P1’s, P2’s, and P4’s case manager had not been informed of and provided copies of the above policies. b. The license holder did not inform and provide copies to P2 of the following policies and procedures affecting P2’s rights within five days of service initiation: · service suspension policy and procedure; and · emergency use of manual restraint policy and procedure. At the time of the review, P2 had not been informed of and provided copies of the above policies. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on February 6, 2023, you were previously found in violation of this same statute. 12. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not use and evaluate positive support strategies as required. a. The license holder did not incorporate in writing to an existing treatment, service, or other individual plan, the positive support strategies to be used when providing services to P1 and P2.
b. The license holder did not evaluate with P3 the identified positive support strategies at least every six months. Statute Violated: Minnesota Rules, part 9544.0030, subpart 1. Repeat Violation: In a Correction Order that DHS issued on September 24, 2019 and February 26, 2023, you were previously found in violation of this same statute. 13. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not maintain documentation of the emergency use of manual restraints policy being provided as required. The license holder did not obtain a written acknowledgement from P1 or P1’s legal representative, P2 or P2’s legal representative, and P4 or P4’s legal representative, that the license holder's policy on the emergency use of manual restraint was provided at service initiation.
Statute Violated: Minnesota Rules, part 9544.0080, subparts 1 and 2. Staffing Standards Violations 14. Violation: For one of ten staff persons whose records were reviewed (SP4), the license holder did not maintain staff qualifications as required. The license holder failed to ensure staff providing direct support were competent as demonstrated through skills and knowledge training, experience, and education relevant to the primary disability of the person and to meet the person’s needs. The license holder failed to maintain documentation of the provider standards and qualifications for SP4 including demonstrated competency in the orientation and training areas required under this chapter. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 3. 15. Violation: For four staff persons whose records were reviewed (SP1, SP2, SP4 and SP5), the license holder did not provide orientation training as required. The license holder did not provide SP1, SP2, SP4 and SP5 with an orientation to the following within 60 calendar days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under Minnesota Statutes, section 245D. 06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the location and access of the license holder’s current policies and procedures, required under Minnesota Statutes, chapter 245D, including staff responsibilities related to implementation of those policies and procedures; · the license holder policy and procedure on emergency use of manual restraint; · 245A.66 and chapter 260E governing maltreatment reporting and service planning for children, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · 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; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on September 24, 2019, and February 26, 2023, you were previously found in violation of this same statute. 16. Violation: For four staff persons whose records were reviewed (SP6-SP9), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide SP6, SP7, SP8, and SP9 with orientation to P1’s individual service recipient needs prior to having unsupervised direct contact with P1. The license holder documented training related to providing services to P1 was completed with SP6, SP7, and SP9, however, no service recipient plans were maintained in the file to provide the required training. Additionally, there was no documentation of SP8 receiving orientation to P1’s individual service recipient needs prior to having unsupervised direct contact. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on September 24, 2019, you were previously found in violation of this same statute 17. Violation: For three staff persons whose record was reviewed (SP3, SP4 and SP5), 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 SP3 and SP5 with annual training on the following topics: · 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; · 245A.66 and chapter 260E governing maltreatment reporting and service planning for children, 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 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 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; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. b. The license holder did not provide SP4 with annual training on the strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on February 26, 2023, you were previously found in violation of this same statute. 18. Violation: For five staff persons whose records were reviewed, (SP1-SP5), the license holder did not maintain personnel records as required. The license holder did not maintain personnel records for SP1-SP5 that documented staff orientation and training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on February 26, 2023, you were previously found in violation of this same statute. False and Misleading Information 19. As a result of a licensing review conducted on July 9-10, 2025, a DHS licensor determined that you knowingly withheld relevant information or provided false and misleading information related to your compliance with licensing rules and laws. The license holder provided progress notes recorded by staff for P1 and P4. P1 and P4 both received night supervision services delivered in their homes. The progress notes for P1 and P4 contained identical statements that P1 and P4 “eloped” on the same dates at the same time despite living in separate houses not near each other. Additionally, the notes included language that did not support night supervision services being provided in the individual’s homes. The progress notes indicated P1 and P4 were found “by the front desk”, “attempting to enter the staff office”, and “wandering near the staff break room”. These notes were also documented as occurring on the same days and at the same time. Citation: Minnesota Statutes, section 245A.07, subdivision 3, paragraph (a), subparagraph (3). Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite ongoing. If you fail to demonstrate substantial compliance with home and community-based services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Nature, chronicity, or severity of violations and effective of violations(s) on health, safety, or rights of persons served by the program The Commissioner considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violations on the health, safety or rights of persons served by the program. Based on this analysis, your license will be placed on a conditional status. · Nature: The license holder was issued a correction order on September 24, 2019, and February 6, 2023. The license holder was required to submit documentation to show compliance with the violations outlined in the correction order issued on February 6, 2023. The license holder provided documentation to DHS that documented further noncompliance. As a result, a notice of noncompliance was issued on April 23, 2023. At the licensing review conducted on July 9-10, 2025, the license holder was not able to demonstrate compliance in multiple areas previously cited for noncompliance, including 13 repeat violations in this order. Furthermore, this order includes 18 violations that affect the health, safety, well-being and overall service delivery of the persons receiving services from the license holder. · Chronicity: Your program received its license on April 27, 2016. During the application process you affirmed that you understood licensing rules and laws. DHS provided you direction and resources regarding these rules and laws, including the importance of compliance. Since April 27, 2016, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o October 9, 2025 Conditional License (this order): 19 violations (13 repeat) o April 23, 2023 Notice of Noncompliance: 4 citations (3 repeat) o February 6, 2023 Correction Order: 12 violations (5 repeat) o September 24, 2019 Correction Order: 9 violations · Severity: Many of the violations involve your inability to complete initial service planning requirements and conduct ongoing evaluations of the services provided. You did not hold initial service planning meetings with individuals served, legal representatives, and case managers as required. Insufficiently completing service planning requirements and ongoing evaluation of services provided to persons served could result in service recipients not receiving accurate, safe, adequate, and competent services from appropriately trained staff. These violations relate to the health, safety, and well-being of persons served and put their health and safety at risk. Additionally, you did not appropriately train your staff in 245D requirements and individual service recipient needs. The training provided to staff at orientation and annually did not sufficiently cover staff responsibilities related to maltreatment reporting, prohibited procedures, and the safe use of manual restraints. You also allowed staff to work unsupervised with persons served prior to receiving instruction and training on individual service recipient needs. Without proper staff training, the vulnerable adults and children in your program are at greater risk of abuse and inadequate support. You did not complete assessments for persons served, both at initiation for services and annually. Assessments are a core component to person centered service planning and delivery as they provide a picture of the person’s served strengths, functional skills and abilities and behavior or symptoms. This information is integral for identifying and implementing the appropriate level of supports and care that is unique to each person. Furthermore, you did not incorporate positive support strategies into the person’s individual plan. Positive supports are approaches that offer respectful and effective ways to help individuals increase quality of life and prevent or reduce behavioral risk. Without these strategies, the person’s behaviors related to their health and medical needs, as well as emotional well-being and personal growth could be negatively impacted. The designated coordinator and designated manager did not provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your program remains in compliance with licensing requirements. License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of your inability to hire a qualified and competent designated coordinator and designated manager, you were found in violation of the 18 citations described in this order. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of: · the program’s operation; · well-being of persons served by your program; · available evaluations of the program by persons receiving services; · information about the training of the direct support staff employed by you; · the ability to demonstrate competent knowledge of applicable laws and rules; and · the results of background studies. DHS is concerned about your program’s operation, well-being of persons served by your program, qualifications of staff, and your ability to demonstrate competent knowledge of applicable laws. DHS is concerned about your program’s operation because since you were licensed in 2016, DHS has issued 4 correction orders, and 18 licensing violations were determined during the most recent licensing review. The number of violations demonstrates that you failed to adequately oversee your responsibilities as a license holder, to ensure compliance, and take corrective action when ordered by the Commissioner. DHS’ concerns about your program’s operation and ability to demonstrate competent knowledge were also demonstrated in your inability to comply with service planning and evaluation requirements. These requirements protect the health and safety of persons served and are minimum standards for license holders. Inability to comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Service planning and evaluation requirements are essential to keeping vulnerable adults and children safe and ensuring persons served are receiving necessary services. Your lack of service planning and documentation of evaluations posed a risk that staff would not know about the unique needs of the vulnerable people served. Additionally, your inability to train your staff providing direct support in how to report and recognize maltreatment, understand prohibited procedures and why they are not safe or effective and how to safely and correctly use emergency manual restraints puts the individuals served by your program at risk. DHS relies on license holders to be truthful. The Commissioner must be able to trust license holders because constant oversight is unreasonable and impossible. License holders must demonstrate an ability to effectively partner with DHS to ensure they are providing person-centered services in compliance with licensing standards. Because DHS has determined that you knowingly provided false and misleading information, DHS cannot be assured that you will be transparent as a provider to vulnerable people, many of whom are unable to advocate for themselves. As a result, DHS is concerned about your ability to provide for the health and safety of the vulnerable people you serve. DHS has determined that an Order of Conditional License is appropriate based on the violations identified above and the program evaluation. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services is placed on a conditional status. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the eighteen violations (thirteen repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. The violations involved your lack of competence to ensure the duties and responsibilities of the designated coordinators and designated managers were met. You did not ensure the designated coordinator provided supervision, support, and evaluation of activities as required. This led to staff providing services to individuals with no knowledge of the services to be provided and the individual needs of the service recipient. Additionally, you did not ensure designated manager identified and implemented corrective action ordered by the commissioner in previous actions. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a managerial staff person, other than SP10, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the persons who will fulfill the duties and responsibilities of your designated coordinator and designated manager for DHS review and approval. It is your responsibility to ensure that these persons meet the necessary qualifications. You must maintain documentation of your designated coordinator and designated manager’s qualifications in their personnel records and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 30 days of receiving this order, you must submit a written plan to DHS detailing how you will: · ensure the corrective action ordered in this order is completed; and · audit all persons served and staff records for compliance with all applicable rules and statutes. The written plans must detail the roles and responsibilities that your designated coordinator and designated manager will have in completing corrective action and auditing all persons served and staff records. 4. Within 60 days of receiving this order, you must: · complete an audit of all persons served and personnel records according to your written plan. The audit must be completed by your designated coordinator and/or designated manager; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · submit the date to your DHS licensor that all person served, and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order. 5. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 6. You may not add additional services to this license for the duration of the conditional license. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at erin.white1@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Erin White Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Home and Community-Based Services laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community-Based Services are required to follow Minnesota 245A, 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Leota Bemis, HCBS Unit Supervisor, at 651-431-5637. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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