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October 15, 2025 Abdirkarim Mohamed, Authorized Agent Multicultural Care Center LLC 3601 Nicollet Avenue Suite 100A Minneapolis, Minnesota 55409 License Number: 1080523 (245D – HCBS) Investigation Number: 202505481 CORRECTION ORDER Dear Abdirkarim Mohamed: On August 13 and 14, 2025 a licensing review and licensing investigation of Multicultural Care Center LLC, located at 3601 Nicollet Avenue, Minneapolis, 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.081. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder did not ensure that the designated coordinator fulfilled the required duties, including the supervision, support, and evaluation of activities 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 CSSP 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 has delegated the responsibility to directly observe the service delivery activities 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. The failure to provide program coordination and oversight of the services provided is evidenced in citations 2 through 17. b. The license holder failed to ensure the designated manager fulfilled the required program management and oversight of the services provided by the license holder, including: · 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, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the services provided is evidenced in citations 2 through 17. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the designated manager and designated coordinator understand and have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and · maintain a signed document that the designated coordinator(s) and designated manager(s) have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’ records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes section 245A.65, subdivisions 1 and 2. Violation: For three of seven persons whose records were reviewed (P1, P2, and P3), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment, and program abuse prevention plans as required. The license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment, and an orientation to the program abuse prevention plan (PAPP) within 24 hours of admission. a. The license holder initiated services for P1 on November 1, 2023. The license holder provided an orientation to P1 to the internal and external reporting procedures related to suspected or alleged maltreatment on February 13, 2024. The license holder did not develop a program abuse prevention plan until August 2025. b. The license holder initiated services for P2 on February 24, 2024.The license holder provided an orientation to P2 to the internal and external reporting procedures related to suspected or alleged maltreatment on May 9, 2024. The license holder did not develop a program abuse prevention plan until July 2024.The license holder did not provide P3 with an orientation to the program abuse prevention plan (PAPP) within 24 hours of admission to the program. c. The license holder initiated services for P3 on January 7, 2025. The license holder did not develop a program abuse prevention plan until August 2025.
Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P2, and P3 with an orientation to the applicable program abuse prevention plan. You must maintain documentation of this in P1, P2 and P3’s support plan addendums. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder did not develop an IAPP for P1 and P2 as part of the initial individual program plan or service plan. · The license holder initiated services for P1 on November 1, 2023 and developed an IAPP for P1 on February 13, 2024. · The license holder initiated services for P2 on February 24, 2024 and developed an IAPP for P2 on May 9, 2024. b. The license holder provided night supervision and individualized home supports with training to P4. The license holder developed an IAPP for P4 did not include specific measures that the program will take to minimize the risk of abuse to P4 within the scope of night supervision and individualized home support with training. Corrective Action Ordered: Within 30 days of receiving this order, you must review and update P4’s IAPP to include the above information. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not provide service recipient rights as required. a. The license holder did not provide a written notice that identified the service recipient rights and an explanation of those rights to P1 and P2 within five working days of service initiation. The license holder initiated services for P1 on November 1, 2023 but did not provide service recipient rights until February 13, 2024. The license holder initiated services for P2 on February 24, 2024 but did not provide service recipient rights until May 9, 2024. b. The license holder did not provide P4 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For two persons whose records were reviewed (P5 and P7), the license holder did not ensure the protection of the person’s rights as required. P5 was residing in a community residential setting (CRS - 1121054). The license holder did not ensure the exercise and protection of P5’s right to a setting that was clean and free from insects. During a site visit on August 13, 2025, DHS licensors observed the following: · a strong odor in P5’s bedroom; and · numerous insects in the house. Corrective Action Ordered: Immediately, you must ensure the exercise and protection all service recipient rights. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivisions 2 and 4. Violation: For one person whose record was reviewed (P1), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for medication administration according to P1’s support plan addendum. The license holder did not ensure the following information was documented in P1’s medication administration record: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use; · the possible consequences if the medication or treatment is not taken or administered as directed; and · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. b. The license holder did not report P1’s refusal to take or receive medication or treatment as prescribed to P1’s case manager. The license holder maintained documentation that P1 refused to take or receive medication as prescribed over 100 times between January 1, 2025 to July 31, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the above information is maintained in P1’s medication administration record; · audit the past six months of P1’s medication administration record to identify refusals or failures to take or receive medication or treatment as prescribed; · based on the results of the audit, report all refusals and failures to take or receive medication or treatment to P1’s case manager; and · maintain documentation of the report provided to P1’s case manager Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. The license holder was assigned responsibility for medication administration according to P1’s support plan addendum. The license holder failed to maintain documentation in P1’s support plan addendum that included a description of the target symptoms that each psychotropic medication was to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P1’s support plan addendum that includes a description of the target symptoms that each psychotropic medication is prescribed to alleviate. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.06, subdivision 1.
Violation: For one person whose record was reviewed (P7), the license holder did not report and review the death of a person as required. The license holder did not report the death of P7 to P7’s case manager, the Department of Human Services Licensing Division and the Office of Ombudsman for Mental Health and Developmental Disabilities within 24 hours. Additionally, the license holder failed to conduct an internal review of P7’s death, including: · whether related policies and procedures were followed; · whether the policies and procedures were adequate; · whether there is a need for additional staff training; · whether the reported event is similar to past events with the services involved; and · whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services. Corrective Action Ordered: Within 30 days of receiving this order, you must; · report the death of P7 to the Department of Human Services Licensing Division and the Office of Ombudsman for Mental Health and Developmental Disabilities; and · conduct an internal review of P7’s death that includes the information outlined above and based on the results of this review, you must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff of the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3. Violation: For one person whose record was reviewed (P4), the license holder did not provide service in response to the person’s identified needs, interest, preferences, as required for each service. 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 provided night supervision and individualized home supports with training for P4. The license holder did not ensure that P4’s support plan addendum identified how services are provided for each service, including how, when and by whom. b. P4’s support plan addendum required annual meetings and written reports regarding P4’s progress or status. The license holder did not participate in service planning and support team meeting for P4 annually in 2023 and 2024. Additionally, the license holder did not provide written reports regarding P4’s progress or status on an annual basis. Corrective Action Required: Within 30 days of receiving this order, you must review and update P4’s support plan addendum to include the information listed above within the scope of each service P4 is receiving. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in these subdivisions. 10. Citation: Minnesota Statutes, section 245D.07, subdivision 1 Violation: For one person whose record was reviewed (P5) the license holder did not comply with the requirements of the federal waiver plan. The license holder maintained video monitoring equipment throughout the program, CRS license number 1121054 where P5 resided and received services. The license holder failed to receive approval for the use of monitoring technology from the lead agency.
Corrective Action Ordered: Within 30 days of receiving this order, you must either remove or receive consent for all monitoring technology being used at the program site. If you choose to continue the use of monitoring technology, you must consult with the case manager for P5 to complete approval and informed consent as outlined in the Community-Based Services Manual (CBSM). Additionally, the same consultation must occur for all service recipient receiving services where monitoring technology is being utilized. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not complete service planning for intensive support services as required. Services were initiated for P1 on November 1, 2023. The license holder completed a preliminary support plan addendum, completed assessments, and participated in an initial planning meeting on February 13, 2024. Services were initiated for P2 on February 24, 2024. The license holder completed a preliminary support plan addendum, completed assessments, and participated in an initial planning meeting on May 9, 2024 a. The license holder did not complete a preliminary support plan addendum within 15 days of service initiation for P1 and P2. b. The license holder did not complete assessments for P1 and P2 in the following areas before providing 45 days of service: · the person’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; · the person’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 · the person’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 behavior that may jeopardize the health and welfare of the person or others. c. The license holder did not hold an initial planning meeting with P1 and P1’s case manager, and P2 and P2’s case manager before providing 45 days of service to determine the following: · the scope of services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; · the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; · opportunities for community access, participation and inclusion in preferred community activities; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team to ensure continuity of care and coordination of services for the person. d. The license holder did not have a discussion with P3, P3’s case manager, and other members of the support team or expanded support team on how technology might be used to meet P3’s desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P3, P3’s case manager and other members of the support team to discuss how technology might be used to meet P3’s desired outcomes. A summary of this discussion including any decisions that were made regarding the use of technology and a description of any further research that needs to be completed before a decision can be made regarding the use of technology, must be included in the support plan addendum for P3 as required. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not develop a service plan that documented the service outcomes and supports as required. The license holder did not document the following supports and methods to be implemented to support P1 and P3 and accomplish outcomes: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the supports and methods listed above for P1 and P3. Additionally, you must provide orientation on the updates to P1’s and P3’s support plan addendum to all staff that provide direct support to P1 and P3. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes for P3. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining progress or daily log notes for all service recipients. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.10, subdivision 3a. Violation: For one person whose record was reviewed (P6), the license holder did not enforce policies and procedures related to service termination as required. The license holder gave P6 notice of service termination on July 23, 2024. The license holder did not: · document actions taken to minimize or eliminate the need for termination prior to giving notice of service termination including: o consultation with P6’s support team or expanded support team to identify and resolve issues leading to issuance of the termination notice; and o request intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support P6 in the program; · notify the commissioner of the intended service termination in writing; and · include the following in the notice of service termination: o a summary of actions taken to minimize or eliminate the need for service termination or temporary service suspensions required under paragraph (c), and why these measures failed to prevent the termination or suspension; o P6’s right to appeal the termination of services under section 256.045, subdivision 3, paragraph (a); and o P6’s right to seek a temporary order staying the termination of services according to the procedures in section 256.045, subdivision 4a or 6, paragraph (c); and · give notice at least 60 days prior to termination. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statues, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. The license holder did not inform and provide copies of the following policies and procedures to P1, P1’s case manager, P2, and P2’s case manager within five working 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. The license holder initiated services for P1 on November 1, 2023 and provided copies of these policies to P1 and P1’s case manager on February 13, 2024. The license holder initiated services for P2 on February 24, 2024 and provided copies of these policies to P2’s case manager on May 9, 2024. Correction Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three of three staff persons whose records were reviewed (SP1-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 to provide SP1 with the following training annually: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices. The license holder provided SP1 this training in January 2024 and July 2025; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. This training was provided in January 2024 and August 2025; · sections 245A.65 and 626.557, governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment, including annual review to VA maltreatment reporting. The license holder most recently provided SP1 this training in January 2024; · 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. This training was provided in January 2024 and August 2025; · 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. This training was provided in January 2024 and August 2025; · basic first aid. This training was provided in January 2024 and July 2025; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. This training was provided in January 2024 and August 2025. b. The license holder did not provide SP2 with the following trainings annually: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices. This training was provided in November 2023 and January 2025; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. This training was provided in November 2023 and January 2025; · 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. This training was provided in November 2023 and January 2025; · 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. This training was provided in November 2023 and January 2025; · basic first aid. This training was provided in November 2023 and January 2025; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. This training was provided in November 2023 and January 2025. c. The license holder did not provide SP3 with annual training regarding the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights in 2023, 2024, or 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 with an annual review of sections 245A.65 and 626.557, governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; and · provide SP3 with training regarding the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. The license holder’s policy and procedures related to suspected or alleged maltreatment failed to identify the primary person or position who would ensure that, when required, internal reviews were completed. The person identified in the policy and procedures was no longer employed with the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the policy and procedures listed above are established as required in this subdivision; · provide a written notice to all persons or their legal representatives and case managers explaining the revision that was made, including a copy of the revised policy and procedure. You must document the reasonable cause for not providing the notice at least 30 days before implementing the revisions; and · inform all employees of the revisions and provide training on implementation of the revised policies and procedures. 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. Nichol Ginther, Human Services Licensor Licensing Division Office of Inspector General 651-431-4822
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