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October 28, 2025 Rose Pratt, Authorized Agent Epic Care Home Services LLC 15373 Iodine Street Northwest Ramsey, Minnesota 55303-5719 License Number: 1108518 (245D – HCBS) CORRECTION ORDER Dear Rose Pratt: On September 25, 2025, a licensing review of Epic Care Home Services LLC, located at 8500 Normandale Lake Boulevard Suite 350 Bloomington, 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 1. Violation: For one of three persons whose record was reviewed (P1), the license holder did not provide orientation to policies and procedures regarding maltreatment as required. The license holder provided multiple services to P1. The license holder did not provide P1 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment within 24 hours of admission for each service that was initiated. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with orientation to your program’s policies and procedures related to suspected or alleged maltreatment; · maintain documentation of this orientation in P1’s service recipient record; · train all staff on your program’s policies and procedures related to suspected or alleged maltreatment; and · maintain documentation of staff training in their personnel records according to Minnesota Statutes, section 245D.095, subdivision 5. 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, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not develop and review individual abuse prevention plans (IAPP) as required. Minnesota Statutes, 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent year. a. The license holder did not develop an IAPP for P1 as part of the initial program plan or service plan for each service that was initiated. b. The license holder provided multiple services to P2. The license holder did not develop an IAPP for P2 that included a statement of measures that would be taken to minimize the risk of abuse to P2 within the scope of each licensed service. c. The license holder did not develop an IAPP for P3 that included a statement of measures that would be taken to minimize the risk of abuse to P3 within the scope of each licensed service. Additionally, the license holder did not review P3’s IAPP with their interdisciplinary team annually in 2025. P3’s IAPP was most recently reviewed in March 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1 that includes an individualized assessment of risk of abuse and P1’s risk for abusing other vulnerable adults and include a statement of measures that will be taken to minimize the risk of abuse within the scope of the licensed services; · develop an IAPP for P2 and P3 that includes statements of measures that will be taken to minimize the risk of abuse within the scope of the licensed services; · review the revised IAPPs with P1, P2, P3, and their interdisciplinary teams; and · maintain documentation of this review in P1’s, P2’s, and P3’s 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. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not provide service recipient rights as required. a. The license holder did not provide P1 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation for each service that was initiated. b. The license holder did not provide P3 with a written notice that identified the service recipient rights and an explanation of those rights annually. The license holder most recently provided P3 with a written notice in April 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 and P3 with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights. You must maintain documentation of P1’s and P3’s receipt of a copy of these rights in their service recipient 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. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not document health service needs as required. a. The license holder was assigned the responsibility of meeting P1’s health needs. The license holder did not maintain documentation on how P1’s health needs would be met including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health service appointments. b. The license holder was assigned the responsibility of meeting P2’s health needs. The license holder did not maintain documentation on how P2’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication set up assistance to P2; · provide medication administration including the administration of P2’s psychotropic pro re nata (PRN) medications; · monitor P2’s blood sugar levels according to written instructions from a licensed health professional; · assist with or coordinate medical, dental, and other health service appointments; and · use P2’s continuous positive airway pressure (CPAP) machine safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must document in P1’s and P2’s records a description of the above mentioned procedures you will follow in order to meet P1’s and P2’s health needs. 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. 5. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not develop 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. The license holder was assigned the responsibility of medication administration for P2 including psychotropic medications. The license holder did not document a description of the target symptoms that each psychotropic medication was to alleviate for P2. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P2’s support plan addendum that includes a description of the target symptoms that each psychotropic medication is 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. 6. Citation: Minnesota Statutes, section 245D.06, subdivision 1 and section 245A.65, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not report and review maltreatment as required. The license holder did not report an incident of suspected maltreatment of P1 within 24 hours of receiving knowledge of the incident, as required in the license holder’s Maltreatment of Vulnerable Adults Mandated Reporting Policy. The suspected maltreatment was reported to the license holder on July 1, 2025. The license holder reported the suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC) on August 18, 2025. Additionally, the license holder did not enforce the program’s policies and procedures related to suspected or alleged maltreatment when the license holder did not ensure that an internal review was completed within 30 calendar days of submitting a maltreatment report concerning P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct an internal review for P1’s maltreatment report that includes the following: o an evaluation of: · 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 person, or the services involved; · whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services; and o based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the license holder, if any. 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.06, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not assist with safekeeping of funds as required.
The license holder was assigned the responsibility of assisting with safekeeping of funds for P2. Within five working days of service initiation, the license holder did not survey and document the preferences for P2’s legal representative and case manager for frequency of receiving a statement that itemized receipts and disbursements of funds. Corrective Action Ordered: Within 30 days of receiving this order, you must survey, document, and implement P2’s legal representative and case manager preferences for frequency of receiving a statement that itemized receipts and disbursements of P2’s funds. 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.07, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not complete service planning for basic support services as required. a. The license holder did not develop P1’s preliminary support plan addendum within 15 calendar days of service initiation for P1’s homemaker and night supervision services. b. The license holder did not review and revise P2’s and P3’s support plan addendums within 60 calendar days of service initiation for each service provided to P2 and P3, to document the services that would be provided including how and when services would be provided. c. The license holder documented in P1’s and P3’s support plan addendums that the expanded support team would meet annually. The license holder did not participate in service planning meetings in 2025 for P1 and P3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a preliminary support plan addendum for P1’s homemaker and night supervision services that documents how services will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services; · review and revise P2’s support plan addendum to document the above-mentioned information for P2’s individualized home supports with training and night supervision services; · review and revise P3’s support plan addendum to document the above-mentioned information for P3’s individual community living supports services; · meet with P1-P3 and P1’s-P3’s expanded support teams; and · maintain documentation of this meeting in P1’s, P2’s, and P3’s 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. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not provide copies of policies and procedures as required. The license holder did not inform and provide copies to P1, P1’s case manager, and P3’s case manager of the following policies and procedures within five working days of service initiation for each service that was initiated: · grievance policy and procedure; and · service suspension and termination policy and procedure. Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the above-mentioned policies and procedures to P1, P1’s case manager, and P3’s case manager and maintain documentation of this in their 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. 10. Citation: Minnesota Rules, 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not incorporate positive support strategies as required. The license holder did not incorporate positive support strategies into writing to an existing treatment, service, or other individual plan for P1, P2, and P3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and incorporate positive support strategies into P1’s, P2’s, and P3’s records; · evaluate the identified positive support strategies with P1, P2, and P3 at least every six months and document the evaluation in the person’s support plan addendums; and · based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. 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 subpart. 11. Citation: Minnesota Rules, 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required. The license holder did not obtain a written acknowledgement from P1 indicating that they had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, sect 245D.04 at the time of service initiation for each service. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain written acknowledgement from P1 that they were notified of your policy on the emergency use of manual restraints and maintain documentation of this notice being provided in their service recipient record. 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 subpart. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For four of five staff persons whose records were reviewed (SP1-SP4), the license holder did not provide orientation training as required. a. The license holder did not provide SP1, SP2, and SP3 with orientation in the following areas within 60 calendar days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures; · 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 and 626.557 governing maltreatment reporting and service planning for 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. b. The license holder did not provide SP4 with orientation in the following areas within 60 calendar days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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 and 626.557 governing maltreatment reporting and service planning for 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1, SP2, SP3, and SP4 with orientation to the above-mentioned trainings; and · maintain documentation of the training in SP1’s, SP2’s, SP3’s, and SP4’s personnel records, including: o the date the training was completed; o the number of hour per subject area, and o the name of the trainer or instructor. 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.09, subdivision 4a. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3) the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide SP1, SP2, and SP3 with an orientation to service recipient needs that included review and instruction on the person’s support plan or support plan addendum, and individual abuse prevention plan, as it relates to the responsibilities assigned to the license holder, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the above mentioned orientation to SP1, SP2, and SP3 and maintain documentation in their personnel records including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. 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.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide annual training as required. Minnesota Statutes, 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent year. The license holder did not provide SP3 and SP4 with annual training in the following areas: · 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 and 626.557 governing maltreatment reporting and service planning for 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. Corrective Action Ordered: Within 30 days of receiving this order, you must complete corrective action ordered in citation 11 for SP3 and SP4. 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. 15. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not provide program coordination, evaluation, and oversight. a. The license holder did not ensure the designated coordinator, SP4, fulfilled the duties of coordination of service delivery and evaluation for persons served by the program. Citations 1 through 11 are evidence of the license holder’s lack of program coordination and oversight of the services provided including: · oversight of the license holder's responsibilities assigned in the person's support plan and the support plan addendum; · instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. The designated coordinator may delegate the direct observation and competency assessment of the service delivery activities of direct support staff to an individual whom the designated coordinator has previously deemed competent in those activities; 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. b. The license holder did not ensure the designated manager, SP4, provided program management and oversight of the services provided by the license holder. Citations 1 through 14 are evidence of the license holder’s lack of program management and oversight of the services provided including: · maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program; · ensuring the program implements corrective action identified as necessary by the program following review of incident and emergency reports according to the requirements in section 245D.11, subdivision 2, clause (7). An internal review of incident reports of alleged or suspected maltreatment must be conducted according to the requirements in section 245A.65, subdivision 1, paragraph (b); · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure SP4 understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; · maintain a signed document that SP4 has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records; and · create an audit tool for service recipient and personnel records and submit to your licensor for approval. Within 60 days of receiving this order, you must: · complete an audit of service recipient and personnel records; · based on the results of your audit, bring service recipient and personnel records into compliance in the areas identified as noncompliant through the audit; · develop and implement a written plan for how you will come into compliance in all areas listed in this correction order; and · maintain documentation of these audits and the written plan in your records for future review by DHS licensors. 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. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at katie.hoard@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Katie Hoard Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Katie Hoard, HCBS Licensor Licensing Division Office of Inspector General 651-431-2656
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