Minnesota

October 17, 2025

Jody Lynn Miller, Authorized Agent

Lutheran Social Service of Minnesota

2485 Como Avenue

Saint Paul, Minnesota 55108-1445

License Number: 1069963 (245D – HCBS)

CORRECTION ORDER

Dear Jody Lynn Miller:

On July 29-August 1, and August 5, 2025, a licensing review of Lutheran Social Service of Minnesota, located at 2485 Como Avenue, Saint Paul, 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 245A.65, subdivision 2.

Violation: For twelve of thirty-six persons whose records were reviewed (P9, P10, P12, P13, P18, P20, P24, P26, P28, P30, P32, and P34), the license holder did not meet abuse prevention plan requirements.

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 develop an individual abuse prevention plan (IAPP) that included a statement of the specific measures to be taken to minimize the risk of abuse to P10, P13, P18, P20, P28, and P34.

· The license holder developed an IAPP that assessed P10 as being vulnerable to sexual abuse. The license holder did not document a statement of the specific measures that would be taken to minimize the risk of sexual abuse to P10.

· The license holder developed an IAPP that assessed P13 as being vulnerable to sexual abuse, self-abuse and financial exploitation. The license holder did not document a statement of the specific measures that would be taken to minimize the risk in those areas to P13.

· The license holder developed an IAPP that assessed P18 as being vulnerable to self-abuse. The license holder did not document a statement of the specific measures that would be taken to minimize the risk of self-abuse to P18. Additionally, the license holder did not assess P18’s risk of abusing other vulnerable adults. P18’s support plan documented that P18 did not understand personal boundaries, may make inappropriate sexual comments, and initiated unwanted, inappropriate contact with others. The license holder did not include this information in P18’s IAPP.

· The license holder developed an IAPP that assessed P20 as being vulnerable to financial exploitation. The license holder did not document a statement of the specific measures to be taken to minimize the risk of financial abuse to P20.

· The license holder developed an IAPP that assessed P28 as being vulnerable to self-abuse and financial exploitation. The license holder did not document a statement of the specific measures to be taken to minimize the risk of self-abuse and financial abuse to P28.

· The license holder developed an IAPP that assessed P34 as susceptible to sexual abuse. The license holder did not document a statement of the specific measures to be taken to minimize the risk of sexual abuse to P34. Additionally, the license holder did not review P34’s IAPP annually in 2023 with the interdisciplinary team.

b. The license holder did not review P9’s and P24’s IAPPs annually in 2024.

· P9’s IAPP was reviewed on April 3, 2023, and April 8, 2025.

· P24’s IAPP was reviewed on November 17, 2023, and December 10, 2024.

c. The license holder did not develop an IAPP as part of the initial individual program plan or service plan prior to or upon service initiation for P12, P26, P30, and P32.

· The license holder initiated P12’s services on June 5, 2024. The license holder developed P12’s IAPP for P12’s annual meeting which occurred on July 24, 2025.

· The license holder initiated P26’s services on August 5, 2024. The license holder developed P26’s IAPP on September 3, 2024.

· The license holder initiated P30’s services on July 6, 2023. At the time of the review, the license holder had not yet developed an IAPP for P30.

· The license holder initiated P32’s services on March 26, 2024. The license holder developed P32’s IAPP on September 20, 2024.

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

· develop an IAPP that includes a statement of the specific measures to be taken to minimize the risk of:

o sexual abuse for P10;

o sexual abuse, self-abuse and financial exploitation for P13;

o self-abuse for P18;

o financial exploitation for P20;

o self-abuse and financial exploitation for P28;

o sexual abuse for P34; and

· develop an IAPP for P30.

Within 60 days of receiving this order, you must:

· review the revised IAPPs for all persons served listed in this citation with each person’s interdisciplinary team. The review must be documented and maintained in each person’s record; and

· provide orientation to the revised IAPP for each person served listed in this citation for each staff person providing direct care services to that person. The orientation must be documented and maintained in each staff person’s record.

On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For seventeen persons whose records were reviewed (P6, P8, P9, P12-P15, P17, P18, P21, P23, P27-30, P33, and P34), the license holder did not provide service recipient rights as required.

a. The license holder did not provide P12 and P23 with a written notice that identified the service recipient rights in subdivisions 2 and 3 and an explanation of those rights within five working days of service initiation.

· The license holder initiated P12’s services on June 5, 2024. The license holder provided written notice on July 24, 2025.

· The license holder initiated P23’s services on November 4, 2022. At the time of the review, the license holder had not yet provided P23 or P23’s legal representative with a written notice.

b. The license holder did not provide P6, P8, P9, P13-P15, P17, P18, P23, P27-P30, P33, and P34, or their legal representatives, if applicable, with a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights annually.

· The license holder did not provide P28 and P29 with this notice annually in 2022, 2023, 2024, and 2025.

· The license holder did not provide P8, P15, P17, and P34 with this notice annually in 2023.

· The license holder did not provide P21, and P23 with this notice annually in 2023 and 2024.

· The license holder did not provide P6, and P9 with this notice annually in 2024.

· The license holder did not provide P27 with this notice annually in 2024.

· The license holder did not provide P30 with this notice annually in 2024 and 2025.

· The license holder did not provide P13 with this notice annually in 2023 and 2025.

· The license holder did not provide P14, P18 and P33 with this notice annually in 2025.

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

· provide P18, P23, P30, and P33 or their legal representatives, if applicable, with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights; and

· maintain documentation of the person or person’s legal representative’s receipt of a copy and an explanation of the rights in each person’s record.

On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.04, subdivision 3.

Violation: For two persons whose records were reviewed (P34 and P35), the license holder did not document and implement the restriction of a person’s rights as required.

a. The license holder maintained documentation in P34’s support plan addendum that stated P34’s right to receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication was restricted due to concerns from P34’s support team regarding P34’s access to communication with others through social media and gaming platforms. The license holder did not document:

· the objective measures set as conditions for ending the restriction;

· a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by P34, P34's legal representative, and case manager; and

· a signed and dated approval for the restriction from P34’s legal representative.

b. The license holder maintained documentation in P35’s support plan that stated P35’s right to have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person and the right to receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication was restricted as of May 8, 2023. The license holder did not document:

· the objective measures set as conditions for ending the restriction;

· a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by P35, P35's legal representative, and case manager; and

· a signed and dated approval for the restriction from P35’s legal representative.

Corrective Action Ordered: Within 30 days of receiving this order, you must document the information detailed above in P34’s and P35’s support plan addendums. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (16).

Violation: For one person whose record was reviewed (P31), the license holder did not ensure the exercise and protection of rights as required.

The license holder did not ensure the exercise and protect P31’s right to access to personal possessions at any time, including financial resources. The license holder kept P31’s checkbook locked in an office building with limited access at a separate location from where P31 resided. P31 did not receive 24 hours services by staff; therefore, P31 did not have access to their financial resources at any time.

Corrective Action Ordered: Immediately upon receiving this order, you must ensure the protection of the right for P31 to have access their financial resources at any time. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 1.

Violation: For six persons whose records were reviewed (P8, P9, P14, P22, P33, and P34), the license holder did not meet health service needs as required.

a. The license holder maintained contradictory information in the same area of P8’s support plan addendum that indicated the license holder was both responsible and not responsible for administration of P8’s psychotropic medications. The license holder did not maintain documentation on how P8’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication administration of P8’s psychotropic medications. Additionally, the license holder documented in P8’s support plan addendum that staff would monitor P8’s intake and elimination and notify P8’s legal representative if there was no elimination for two days. The license holder stated that staff were not monitoring P8’s elimination.

b. The license holder was assigned responsibility for meeting P14’s health needs. The license holder did not maintain documentation on how P14’s health needs would be met, including a description of the procedures the license holder would follow in order to:

· monitor P14’s seizures according to written instructions from a licensed health professional; and

· provide medication administration of P14’s psychotropic pro re nata (PRN) medications.

c. The license holder was assigned responsibility for administering psychotropic PRN medications for P9, P22, P33, and P34. The license holder did not maintain documentation on how P9’s, P22’s, P33’s and P34’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication administration of P9’s, P22’s, P33’s, and P34’s PRN psychotropic medications.

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

· review and revise P8’s support plan addendum to document how medication administration is provided to P8 according to the requirements of this chapter; and

· document how the health needs for P9, P22, P33 and P34 will be met, including a description of the procedures the license holder will follow in order to safely administer psychotropic medication.

On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.05, subdivision 1a.

Violation: For three persons whose records were reviewed (P4, P9, and P34), the license holder did not document medication setup as required.

The license holder was assigned responsibility for medication setup to P4, P9, and P34. The license holder did not document:

· the times the medications were to be administered in P4’s medication administration record (MAR);

· the dates of medication setup in P9’s MAR in April 2025 and June 2025; and

· the dates of medication setup in P34’s MAR from January 2025 through July 2025.

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

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

Violation: For five persons whose records were reviewed (P7, P9, P22, P24, and P32), the license holder did not document medication administration as required.

a. The license holder did not maintain the following information in P7’s and P9’s MARs for all

medications prescribed to P7 and P9:

· information on any risks or 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

· instructions 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 maintain the following information in P22’s MAR for all medications prescribed to P22:

· information on the current prescription label or the prescriber’s current written or electronically recorded order or prescription that includes the person’s name, description of the medication or treatment to be provided, and the frequency and other information needed to safely and correctly administer the medication or treatment to ensure effectiveness;

· information on any risks or other side effects that are reasonable to expect, and any contraindications to its use; and

· the possible consequences if the medication or treatment is not taken or administered as directed.

c. The license holder did not maintain the following information in P24’s MAR for all medications prescribed to P24:

· information on any risks or other side effects that are reasonable to expect, and any contraindications to its use; and

· the possible consequences if the medication or treatment is not taken or administered as directed.

d. The license holder did not obtain a signed authorization from P32’s legal representative to administer medications or treatments prior to administering medications or treatments. The license holder initiated P32’s services on March 26, 2024. The license holder documented in P32’s MAR that the license holder first administered P32’s medications on March 26, 2024. The license holder obtained written authorization to administer medications or treatment from P32’s legal representative on April 4, 2024.

Corrective Action Ordered: Within 30 days of receiving this order, you must include the above-mentioned information in P7’s, P9’s, P22’s, and P24’s MARs. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For nine persons whose records were reviewed (P5-P7, P9, P11, P15, P17, P32, and P33), the license holder did not review medication administration records as required.

a. The license holder did not report medication errors or refusals to P5’s or P6’s legal representatives and case managers:

· P5’s MAR indicated medication errors or refusals in July 2024, January 2025, and June 2025.

· P6’s MAR indicated medication errors or refusals from January 2025 through June 2025.

b. The license holder did not conduct MAR reviews for P7, P9, P15, P17, P32, and P33, at least every three months:

· in 2023 and 2024 for P7 and P9;

· in 2023, 2024 and 2025 for P15;

· in 2022, 2023, 2024 and 2025 for P17; and

· in 2024 and 2025 for P32 and P33.

c. The license holder did not complete accurate MAR reviews for P5, P6, and P11 when the license holder did not identify patterns of medication administration errors:

· for P5 in July 2024, January 2025, and June 2025;

· for P6 from January 2025 through June 2025; and

· for P11 from April 2024 through June 2024.

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

· review the MARs from June 2025 to current for all service recipients listed in this citation to ensure the information is current and to identify medication administration errors;

· based on the review, report identified medication errors to each person’s legal representative and case manager as applicable;

· develop and implement a plan to correct patterns of medication administration errors when identified;

· maintain documentation of notifications regarding medication errors; and

· maintain documentation of all medication administration record reviews in each service recipient’s record according to Minnesota Statutes, section 245D.095, subdivision 3.

On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For nine persons whose records were reviewed (P6, P7, P9, P22, P24, and P32-P35), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required.

"Target symptom" refers to any perceptible diagnostic criteria for a person's diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation.

a. The license holder was assigned the responsibility of medication administration for P7, P9, P22, P24, P32, P33, P34 and P35. The license holder did not document the target symptoms that each psychotropic medication prescribed to the person was to alleviate.

b. The license holder was assigned the responsibility of collecting and reporting psychotropic medication and symptom related data to the prescriber for P6 and P32.

· The license holder did not provide the psychotropic medication monitoring data reports annually as assigned for P6 in 2024.

· The license holder did not provide the psychotropic medication monitoring data reports quarterly as assigned for P32 in 2024 and 2025.

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

· update the support plan addendums for P7, P9, P22, P24, P32, P33, P34 and P35 to include a description of the target symptoms that each prescribed psychotropic medication is to alleviate; and

· collect and report on P32’s medication and symptom-related data as assigned.

On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Statutes, section 245D.06, subdivision 1.

Violation: For one person whose record was reviewed (P34), the license holder did not report and review an incident as required.

P34 was involved in an incident that occurred on April 27, 2025. The license holder did not include in the incident report whether P34’s support plan addendum or program policies and procedures were implemented as applicable. Additionally, the license holder did not report this incident to P34’s legal representative and case manager within 24 hours of occurrence.

Corrective Action Ordered: Within 30 days of receiving this order, you must notify P34’s legal representative and case manager of this incident and document in P34’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For nine persons whose records were reviewed, (P5, P7, P15, P17, P21, P23, P32, P34, and P35), the license holder did not meet the requirements for safekeeping and handling a person’s funds and property.

a. P5’s authorization to safekeep funds documented that P5’s legal representative and case manager requested monthly statements that itemized receipts and disbursement of funds. The license holder did not provide monthly statements to P5’s legal representative and case manager.

b. P7’s authorization to safekeep funds documented that P7 and P7’s case manager requested annual statements that itemized the receipts and disbursements of funds. The license holder did not provide these statements to P7 and P7’s case manager in 2023, 2024, and 2025.

c. The license holder did not obtain written authorization annually in 2023 from P15 or P15’s legal representative and P15’s case manager to assist P15 with the safekeeping of funds or other property. Additionally, the license holder’s written authorization for P15 identified quarterly itemized statements. The license holder did not maintain itemized quarterly statements in P15’s record.

d. The license holder did not obtain written authorization annually in 2022, 2023, 2024 and 2025 from P17 or P17’s legal representative and P17’s case manager to assist P17 with the safekeeping of funds or other property.

e. The license holder did not obtain written authorization from P21’s and P23’s legal representatives and P21’s and P23’s case managers for safe keeping of funds within five working days of service initiation. Additionally, the license holder did not obtain written authorization from P21’s and P23’s legal representatives annually in 2023 and 2024.

f. The license holder initiated P32’s services on March 26, 2024. The license holder did not obtain written authorization for safekeeping of funds or property from P32’s legal representative and case manager within five working days of service initiation. The license holder obtained the initial authorization from P32’s legal representative on April 4, 2024, and P32’s case manager on April 2, 2025. Additionally, the license holder did not obtain authorization from P32’s legal representative annually in 2025. The license holder did not survey and document the preferences of the P32, P32’s legal representative and P32’s case manager for frequency of receiving a statement that itemized receipts and disbursements of funds when the initial authorization was obtained.

g. The license holder did not obtain written authorization from P34’s legal representative and P34’s case manager to assist with the safekeeping of P34’s funds annually in 2023.

h. The license holder did not implement the preferences of P35’s legal representative and case manager for receiving a statement that itemizes receipts and disbursement of funds on a semi-annual basis.

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

· provide a statement to P5’s and P35’s case managers and legal representatives;

· provide P7 and P7’s case manager with the statements identified above;

· obtain written authorization to assist P15, P17, P21 P23, and P32 with the safekeeping of funds or other property from their legal representatives, if applicable, and case managers;

· survey, document and implement the preferences of the person, the legal representative and the case manager for frequency of receiving a statement that itemized receipts and disbursements of funds;

· maintain itemized statements as preferred by the person or the person’s legal representative and the person’s case manager;

· maintain documentation in person served records when the program sends financial statements to case managers and legal representatives.

On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.06, subdivision 5.

Violation: For one person whose record was reviewed (P36), the license holder employed a prohibited procedure.

The license holder did not prohibit the use of prohibited procedures when the license holder utilized a mechanical restraint for P36. During a site visit to the facility where P36 resided, DHS licensors observed that the license holder utilized an enclosed canopy on P36’s bed that would not allow P36 to exit their bed without assistance from a staff person.

Corrective Action Ordered: Immediately upon receiving this order, you must discontinue the use of prohibited procedures for P36, or you must contact the External Program Review Committee with DHS Disability Services Positive Supports to seek approval for the procedure. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. Citation: Minnesota Statutes, section 245D.061, subdivision 6.

Violation: For one person whose record was reviewed (P33), the license holder did not complete and document an internal review of an emergency use of manual restraint (EUMR) as required.

The license holder did not complete and document an internal review of an EUMR that occurred with P33 on March 20, 2024, that included an evaluation of whether:

· the person's service and support strategies developed according to sections 245D.07 and 245D.071 need to be revised;

· related policies and procedures were followed;

· the policies and procedures were adequate;

· there is a need for additional staff training;

· the reported event was similar to past events with the persons, staff, or the services involved; and

· there was a need for corrective action by the license holder to protect the health and welfare of persons.

Corrective Action Ordered: Within 60 days of receiving this order, you must complete an internal review for the use of emergency use of manual restraint that involved P33. You must:

· develop, document, and implement a corrective action plan for the program designed to correct current lapses and prevent future lapses in performance by individuals or the license holder, if any. The corrective action plan, if any, must be implemented within 30 days of the internal review being completed;

· maintain a copy of the internal review for P33 and the corrective action plan, if any, in the person’s service recipient record;

· consult with the expanded support team following the emergency use of manual restraint to:

o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identify the perceived function the behavior served;

o determine whether the person's support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint; and

o maintain a written summary of the expanded support team's discussion and decisions required in paragraph (a) in the person's service recipient record.

On an ongoing basis, you must maintain compliance as required in this subdivision.

14. Citation: Minnesota Statutes, section 245D.07, subdivision 2.

Violation: For seven persons whose records were reviewed (P4-P6, P21, P23, P25, and P31), the license holder did not meet service planning requirements for basic support services.

a. The license holder provided multiple services to P4, P5 and P6. The license holder did not identify how individualized home supports with training and night supervision would be provided in P4’s, P5’s, and P6’s support plan addendums including how, when, by whom and the person(s) responsible for overseeing the delivery and coordination.

b. The license holder initiated P23’s services on November 4, 2022. The license holder did not complete a preliminary support plan addendum for P23 within 15 days of service initiation as required. Additionally, the license holder did not review and revise P23’s preliminary support plan addendum within 60 calendar days of service initiation to document the services that will be provided including how, when, and by whom services will be provided.

c. The license holder did not maintain documentation of participation in service planning meetings and support team meetings for P21 and P23 annually in 2023, and 2024. P21’s and P23’s support plan addendums indicated that P21 and P23 and their expanded support teams would meet annually.

d. The license holder initiated services for P25 on October 22, 2024. The license holder did not review and revise P25’s preliminary support plan addendum within 60 calendar days of service initiation to document 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.

e. The license holder initiated P31’s basic services on April 1, 2025. The license holder did not review and revise P31’s preliminary support plan addendum with 60 calendar days of P31’s service initiation. The license holder completed the preliminary support plan addendum on June 25, 2025.

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

· review and revise P4’s, P5’s, and P6’s support plan addendums to include the above-mentioned information for each service the person receives;

· review and revise, as needed, P25’s preliminary support plan addendum; and

· maintain documentation in the record of each person served of participation in service planning meetings and support team meetings as assigned in the support plan or support plan addendum.

On an ongoing basis, you must maintain compliance as required in this subdivision.

15. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b).

Violation: For seven persons whose records were reviewed (P12, P13, P17, P18, P22, P30, and P34), the license holder did not meet the assessment requirements for intensive support service planning.

a. The license holder did not complete assessments for P22 that produced information that described the person’s overall strengths, functional skills and abilities, and behaviors or symptoms.

b. The license holder did not complete assessments for P12, P13 and P30 before providing 45 days of service in the following areas:

· 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 behaviors that may jeopardize the health and welfare of the person or others.

Additionally, the license holder did not complete the assessments in the above areas for P17 in 2023, and P18 in 2025.

c. The license holder did not complete assessments for P34’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, risk of falling and mobility.

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

· complete an assessment of overall strengths, functional skills and abilities, and behaviors or symptoms for P22;

· complete the above-mentioned assessments for P12, P13, P18, P30, and P34;

· review the results with each person and their support teams; and

· maintain copies in each person’s service recipient record as required in section 245D.095, subdivision 3.

On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c).

Violation: For six persons whose records were reviewed (P7, P12, P13, P30, P32, and P33), the license holder did not meet initial service planning requirements for intensive support services.

a. The license holder did not hold an initial service planning meeting with P7, P7’s case manager, and other members of the support team or expanded support team before providing 45 days of service.

b. The license holder did not determine the following based on information obtained from the assessments identified in paragraph (b), the person’s identified needs in the support plan, and the requirements in subdivision 4 and section 245D.07, subdivision 1a at the initial service planning meeting for P12, P13, P30, P32, and P33.

· For P13, the license holder did not determine:

o how technology might be used to meet the person's desired outcomes.

· For P12 and P30, the license holder did not determine:

o the scope of the services to be provided to support the person's daily needs and activities;

o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

o 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;

o whether the current service setting is the most integrated setting available and appropriate for the person;

o opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences;

o opportunities for community access, participation, and inclusion in preferred community activities;

o opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community;

o opportunities to seek competitive employment and work at competitively paying jobs in the community;

o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and

o how technology might be used to meet the person's desired outcomes.

· For P32, the license holder did not determine:

o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

o opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences;

o opportunities for community access, participation, and inclusion in preferred community activities;

o opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; and

o how technology might be used to meet the person's desired outcomes.

· For P33, the license holder did not determine:

o opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; and

o how technology might be used to meet the person's desired outcomes.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· meet with P12, P13, P30, P32, P33, and their legal representatives and case managers to determine the above-mentioned information; and

· have a discussion of how technology might be used to meet P12’s, P13’s, P30’s, P32's and P33’s desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include:

o a statement regarding any decision that is made regarding the use of technology; and

o a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

On an ongoing basis, you must maintain compliance as required in this subdivision.

17. Citation: Minnesota Statutes, section 245D.071, subdivision 4.

Violation: For thirteen persons whose records were reviewed (P7-P9, P15-P17, P22, P27, P30, and P32-P35), the license holder did not develop and document service outcomes and supports as required.

The license holder did not document the supports and methods to be implemented to support P7, P8, P9, P15, P16, P17, P22, P27, P30, P32, P33, P34, and P35 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being.

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

· develop and document the following information in the service plan of each person listed above in this citation:

o the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about:

· any changes or modifications to the physical and social environments necessary when the service supports are provided;

· any equipment and materials required; and

· techniques that are consistent with the person’s communication mode and learning style;

o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected;

o 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

o the names of the staff or position responsible for implementing the supports and methods.

On an ongoing basis, you must maintain compliance as required in this subdivision.

18. Citation: Minnesota Statutes, section 245D.071, subdivision 5.

Violation: For twelve persons whose records were reviewed (P7-P13, P15, P17, and P33-P35), the license holder did not meet the requirements for service plan review and evaluation.

a. The license holder did not include the following information in the progress review reports for P7-P13, P15, P17, P33, P34, and P35:

· status and progress toward achieving the identified outcomes;

· recommendations; and

· rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4.

b. The license holder did not participate in progress review meetings for P9 following the timelines established in P9’s support plan addendum. P9’s support plan addendum documented that progress review meetings would be conducted semiannually. The license holder conducted these meetings annually.

c. The license holder did not discuss the following with P34, P34’s legal representative and members of the expanded support team in 2023 and 2024:

· how technology might be used to meet P34’s desired outcomes; and

· options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider.

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

19. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For five of fifty-six staff persons whose records were reviewed (SP2, SP7, SP8, SP10, and SP32), the license holder did not meet program abuse prevention plan (PAPP) requirements.

a. The license holder did not provide SP7 and SP8 with an orientation to the PAPP within 72 hours of SP7 and SP8 first providing direct contact services to a vulnerable adult.

b. SP10’s date of hire was December 27, 2023. The license holder did not provide SP10 with an orientation to the PAPP within 72 hours of SP10 first providing direct contact services to a vulnerable adult. The license holder provided SP10 with an orientation to the PAPP on March 13, 2024.

c. The license holder did not provide an annual review of the PAPP to SP2 in 2023, and 2025. The license holder last provided SP2 with a review of the PAPP on March 18, 2024.

d. The license holder did not provide an annual review of the PAPP to SP32 in 2021, 2022, 2023 and 2024. The license holder provided SP32 with a review of the PAPP on September 8, 2020, and on April 7, 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP7 and SP8 with an orientation to the program’s PAPP and provide SP2 with an annual review to the program’s PAPP. You must maintain documentation of this orientation in SP7 and SP8’s personnel records, and the annual review in SP2’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For eighteen staff persons whose records were reviewed (SP1-SP3, SP10, SP11, SP13, SP14, SP17, SP33, SP34, SP36, SP37, SP39, SP40, SP41, SP44, SP46, and SP48), the license holder did not provide orientation training as required.

a. SP1 was hired July 19, 2023. The license holder did not provide SP1 with the following training within 60 days of hire:

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied 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 restraints, time out, seclusion including chemical restraints; and

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe.

b. SP2 was hired July 15, 2023. The license holder did not provide SP2 with the following training within 60 days of hire:

· the job description and how to complete specific job functions including:

o responding to incidents as required under Minnesota Statutes, section 245D.06, subdivision 1;

o following safety practices established by the license holder as required in section 245D.06, subdivision 2;

· the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· 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 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;

· 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 manual restraints, time out, and seclusion including chemical restraint; and

c. SP3 was hired November 11, 2022. The license holder did not provide SP3 with the following training within 60 days of hire:

· 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;

· 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.

d. SP10 was hired December 27, 2023. The license holder did not provide SP10 with the following training within 60 days of hire:

· strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities within 60 days of hire.

The license holder provided this training to SP10 on a later date.

e. SP11 was hired February 24, 2025. The license holder did not provide SP11 with the following training within 60 days of hire:

· the job description and how to complete specific job functions including:

o responding to incidents as required under Minnesota Statutes, section 245D.06, subdivision 1;

o following safety practices established by the license holder as required in section 245D.06, subdivision 2;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

f. SP13 was hired April 2, 2024. The license holder did not provide SP13 with the following training within 60 days of hire:

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

g. SP14 was hired January 31, 2024. The license holder did not provide SP13 with the following training within 60 days of hire:

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

h. SP17 was hired January 16, 2024. The license holder did not provide SP17 with the following training within 60 days of hire:

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy to people with disabilities.

i. SP33 was hired March 1, 2025. The license holder did not provide SP33 with the following training within 60 days of hire:

· 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.

j. SP34 was hired March 17, 2025. The license holder did not provide SP34 with the following training within 60 days of hire:

· 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; and

The license holder provided these trainings to SP34 on a later date.

k. SP36 was hired May 6, 2024. The license holder did not provide SP36 with the following training within 60 days of hire:

· 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;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy to people with disabilities.

l. SP37 was hired October 4, 2022. The license holder did not provide SP37 with the following training within 60 days of hire:

· 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; and

The license holder provided these trainings to SP37 on a later date.

m. SP39 was hired January 10, 2023. The license holder did not provide SP39 with the following training within 60 days of hire:

· 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;

· sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3;

The license holder provided these trainings to SP39 on a later date.

n. SP40 was hired January 22, 2024. The license holder did not provide SP40 with the following training within 60 days of hire:

· the license holder’s current policies and procedures required under this chapter, including their name and access, and staff responsibilities related to implementation of those policies and procedures;

· the service recipient rights and responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy to people with disabilities.

The license holder provided these trainings to SP40 on a later date.

o. SP41 was hired October 20, 2022. The license holder did not provide SP41 with the following training within 60 days of hire:

· the service recipient rights and responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy to people with disabilities.

The license holder provided these trainings to SP41 on a later date.

p. SP44 was hired March 22, 2023. The license holder did not provide SP44 with the following training within 60 days of hire:

· the service recipient rights and responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· basic first aid;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and

· cardiopulmonary resuscitation (CPR) training as identified as necessary training for all staff persons by the license holder.

q. SP46 was hired November 22, 2024. The license holder did not provide SP46 with the following training within 60 days of hire:

· basic first aid;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and

· cardiopulmonary resuscitation (CPR) training as identified as necessary training for all staff persons by the license holder.

r. SP48 was hired November 18, 2022. The license holder did not provide SP48 with the following training within 60 days of hire:

· the service recipient rights and responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; and

Corrective Action Ordered: Within 60 days of receiving this order, you must ensure that each staff person listed in this citation has received the above-mentioned trainings. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For ten staff persons whose records were reviewed (SP1-SP3, SP8, SP11, SP17, SP36, SP44, SP48, and SP51), the license holder did not provide orientation to individual service recipient needs as required.

a. The license holder did not provide SP1, SP2, SP3, SP8, SP11, SP17, SP36, SP44, and SP48 with the following training before having unsupervised direct contact with a person served by the program:

· the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder; and

· the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual and how to implement those plans.

b. The license holder did not provide SP1, SP44, and SP51 with instruction on the following medication administration procedures before providing medication administration to a person served by the program:

· completion of a medication administration training from a curriculum developed by a registered nurse or appropriate licensed health professional; and

· completion of an observed medication administration skill assessment by the trainer to ensure unlicensed staff demonstrated the ability to safely and correctly follow medication procedures.

Corrective Action Ordered: Within 30 days of receiving this order, you must ensure SP1, SP2, SP3, SP8, SP11, SP17, SP36, SP44, SP48 and SP51 have reviewed and received instruction on each of the requirements identified above for every service recipient to whom they provide direct support services. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For eleven staff persons whose records were reviewed (SP2-SP4, SP13, SP19, SP20, SP24, SP25, SP39, SP41, and SP43), the license holder did not provide annual training as required.

a. The license holder did not provide SP2 with annual training on data privacy requirements according to Minnesota Statutes, section 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 did not provide this training to SP2 in 2024. SP2 received this training on February 11, 2025.

b. The license holder did not provide SP3 with annual training in 2024 on 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. SP3 last received this training on October 31, 2023.

c. The license holder did not provide SP4 with annual training in 2024 on data privacy requirements according to Minnesota Statutes, section 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. SP4 received this training on February 15, 2023, and February 11, 2025.

d. The license holder did not provide SP13 with annual training in 2025 on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent and bodily autonomy of people with disabilities. SP13 last received this training on June 12, 2024.

e. The license holder did not provide SP19 with the following annual training:

· data privacy requirements according to 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 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, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3;

· 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.

The license holder informed licensors that SP19 did not have a record of documented training. Licensors were unable to determine when SP19 completed these trainings.

f. The license holder did not provide SP20 with the following annual training:

• data privacy requirements according to 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. SP20 last received this training in February 2022;

· 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. SP20 received this training in October 2021, and March 2025;

· 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. SP20 received this training in June 2021 and March 2025;

· basic first aid. SP20 received this training in September 2021 and March 2025; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. SP20 received this training in August 2021, and March 2025.

g. The license holder did not provide SP24 with annual training in 2024 on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder provided SP24 with this training on August 23, 2023, and July 19, 2025.

h. The license holder did not provide SP25 with the following annual training in 2024:

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

i. SP39 The license holder did not provide SP39 with annual training in 2024 on 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. SP39 received this training in June 2023, and October 2024.

j. The license holder did not provide SP41 with annual training in 2025 on 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. SP41 last received this training in June 2024.

k. The license holder did not provide SP43 with the following annual training:

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. SP43 received this training in August 2022, September 2023, and August 2024.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· provide SP3 with training on 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;

· provide SP19 with the above-mentioned trainings;

· provide SP20 with training on data privacy requirements according to 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; and

· provide SP41 with annual training in 2025 on 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.

On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For ten persons whose records were reviewed (P11, P18-P21, P23, P27, P32, P30, and P34), the license holder did not maintain service recipient records as required.

a. The license holder did not maintain progress or daily log notes for P18-P21, P23, P27, and P30 in each person’s service recipient record.

b. The license holder did not protect service recipient records from loss. The license holder told DHS licensors that P11’s service recipient records from 2022 could not be located, and P34’s service recipient records from 2023 could not be located.

Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for all service recipients. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For eighteen staff persons whose records were reviewed (SP2, SP11, SP12, SP18, SP19, SP28, SP32, SP37 SP39–SP43, and SP44–SP48), the license holder did not maintain personnel records as required.

a. The license holder did not maintain documentation for SP2 in the personnel record or elsewhere, sufficient to determine the date of SP2’s first supervised and unsupervised direct contact with persons served by the program.

b. The license holder did not maintain a personnel record for SP28, SP32, SP37 and SP39-SP48 that documented the number of hours per subject area for each training completed. Additionally, the license holder did not maintain a personnel record that included the name of the trainer or instructor for SP28 and SP32.

c. The license holder did not maintain a personnel record for SP11, SP12, SP18 and SP19 that documented annual training, including:

· the date the training was completed;

· the number of hours per subject area; and

· the name of the trainer or instructor.

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

25. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For four persons whose records were reviewed (P12, P20, P23, P32), the license holder did not provide written or electronic copies of policies and procedures as required.

a. The license holder did not inform P12 and P12’s case manager, P20’s case manager, and P32’s case manager of the following policies and procedures 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.

b. The license holder did not inform P23 of the following policies and procedures within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure; and

· emergency use of manual restraints policy and procedure.

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

· provide P12 and P12’s case manager, P23 and P23’s legal representative, and P20’s case manager, and P32’s case manager with the above-mentioned policies and procedures; and

· obtain a written acknowledgement from P12 and P23’s legal representative that the person has been notified of the program’s policy on the emergency use of manual restraints as required in Minnesota Rules, part 9544.0080. You must maintain the written acknowledgement in the person’s record.

On an ongoing basis, you must maintain compliance as required in this subdivision.

26. Citation: Minnesota Rules, part 9544.0030, subpart 1.

Violation: For ten persons whose records were reviewed (P6, P9, P12, P13, P15, P17, P21, P23, P30, and P34), the license holder did not evaluate positive support strategies as required.

The license holder did not review positive support strategies every six months for P6, P9, P12, P13, P15, P17, P21, P23, P30, and P34.

Corrective Action Ordered: Within 30 days of receiving this order, you must ensure the positive support strategies for each person served listed in this citation are reviewed according to the standards in part 9544.0030, subparts 2, 3, and 4. On an ongoing basis, you must maintain compliance as required in this subpart.

27. Citation: Minnesota Rules, part 9544.0110.

Violation: For two persons whose records were reviewed (P33 and P35), the license holder did not use the behavior intervention report form (BIRF) required by the commissioner to report incidents.

a. The license holder did not use the BIRF required by the commissioner to report the following incidents involving P33:

· a behavioral incident that resulted in a call to 911 that occurred on December 8, 2024; and

· an emergency use of manual restraint that occurred on March 20, 2024.

b. The license holder did not use the BIRF required by the commissioner to report the following behavioral incidents involving P35 that resulted in calls to 911:

· June 30, 2022;

· May 14, 2025;

· May 20, 2025;

· July 9, 2025; and

· July 15, 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must use the BIRF required by the commissioner to report the above incidents for P33 and P35. On an ongoing basis, you must maintain compliance as required in this subpart.

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

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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.

Dylan Sobota, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-2690

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