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October 31, 2025 Krystle Glad, Authorized Agent Range Center Incorporated 1001 8th Avenue Northwest, PO Box 629 Chisholm, Minnesota 55719-1148 License Number: 1068850 (245D – HCBS) 1068862 (Day Services Facility) 1073028 (Day Services Facility) 1068856 (Community Residential Services) 1068858 (Community Residential Services) 1116091 (Community Residential Services) 1116637 (Community Residential Services) CORRECTION ORDER Dear Krystle Glad: On September 8, 2025, through September 10, 2025, a licensing review of Range Center Incorporated, located at 1001 8th Avenue Northwest, Chisholm, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: For six of twelve staff persons whose records were reviewed (SP6, SP8, SP9, SP10, SP11, SP12), the license holder did not ensure coordination and evaluation of services was provided by a designated staff person as required. The license holder did not ensure that SP6, SP8, SP9, SP10, SP11, and SP12 met the minimum education, training, and work experience requirements prior to designating SP6, SP8, SP9, SP10, SP11, and SP12 as the staff person responsible for the duties of the designated coordinator including: · a minimum of 50 hours of education and training related to human services and disabilities; and · four years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older under the supervision of a staff person who meets qualifications identified in clauses (1) to (3). Corrective Action Ordered: Within 60 days of receiving this order, you must: · designate a staff person(s) other than SP6, SP8, SP9, SP10, SP11, and SP12 to be responsible for the job duties of the designated coordinator outlined in 245D.081, subdivision 2, paragraph (a); · verify the work experience and qualifications for the person(s) you have designated to perform the duties of the designated coordinator; and · submit to your licensor the name and qualifications of the person(s) you have identified to perform the duties of the designated coordinator. 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.04, subdivision 13. Violation: For one of eleven persons whose records were reviewed (P3), the license holder did not ensure separation of persons served funds as required. The license holder was assigned the responsibility to assist P3 with safekeeping of funds. The license holder reported at the time of the review that all person served funds are put into one business bank account. The license holder did not ensure the separation of funds for P3 by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · separate funds for all person’s served when you are assigned to assist with the safekeeping of funds; and · submit a written plan to your licensor detailing how you will maintain compliance in this subdivision. 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 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not ensure the program abuse prevention plans (PAPP) were reviewed as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder did not review the program abuse prevention plans for the day service facilities at least annually as required. The program abuse prevention plans were documented as having been reviewed in March 2022, July 2023, and June 2025. Corrective Action Ordered: 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 245A.65, subdivision 2, paragraph (a). Violation: For one person whose record was reviewed (P3), the license holder did not provide orientation to the license holder’s program abuse prevention plan (PAPP) as required. The license holder did not provide P3 with an orientation to the PAPP within 24 hours of admission when moving from one location to another location controlled by the license holder. Corrective Action Ordered: Within 30 days of receiving this order you must provide P3 with an orientation to the PAPP. 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 245A.65, subdivision 2, paragraph (b). Violation: For five persons whose records were reviewed (P3, P7, P9, P10, and P11), the license holder did not develop an individual abuse prevention plan (IAPP) as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder did not review and evaluate P3’s IAPP annually in 2022. b. The license holder did not develop an IAPP for P7 prior to or upon service initiation. The license holder initiated services for P7 on July 3, 2023. The IAPP in the record was not dated or signed by P7 or P7’s case manager. Additionally, the license holder documented P7 was susceptible to physical abuse, sexual abuse, self-abuse, and financial exploitation. The license holder did not include in the IAPP a statement of the specific measures to be taken to minimize the risk of abuse to P7 in these areas and the specific actions the program would take to minimize the risk of abuse within the scope of licensed services. c. The license holder documented in the IAPP for P9 that P9 was susceptible to sexual abuse, physical abuse, and financial exploitation. The license holder did not include in the IAPP a statement of the specific measures to be taken to minimize the risk of abuse to P9 in these areas and the specific actions to be taken to minimize the risk of abuse within the scope of licensed services. d. The license holder did not develop an IAPP for P10 prior to or upon service initiation. The license holder initiated services for P10 on June 2, 2025, and at the time of the review an IAPP had not yet been developed for P10. e. The license holder did not develop an IAPP for P11 prior to or upon service initiation. The license holder initiated services for P11 on July 22, 2025, and at the time of the review, an IAPP had not yet been developed for P11. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update the IAPP for P7 to include the specific measures and actions to be taken to minimize the risk of abuse to P7 in the identified areas of susceptibility; · review the updated IAPP with P7, P7’s legal representative, and P7’s case manager and document this review in P7’s service recipient record; · provide training to all staff that work with P7 on the updated IAPP and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area and the name of the trainer or instructor; · update the IAPP for P9 to include the specific measures and actions to be taken to minimize the risk of abuse to P9 in the identified areas of susceptibility; · review the updated IAPP with P9, P9’s legal representative and P9’s case manager and document this review in P9’s service recipient record; · provide training to all staff that work with P9 on the updated IAPP and document this training in the personnel record, including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; · develop an IAPP for P10 and P11 that contains the requirements below: o an individualized assessment of P11’s susceptibility to abuse by other individuals, including other vulnerable adults, P11’s risk of abusing other vulnerable adults, and statements of the specific measures to be taken to minimize the risk of abuse to P11 and other vulnerable adults; and o the specific actions you will take to minimize the risk of abuse within the scope of licensed services; · review the IAPP with P10, P11, P10’s legal representative, P11’s legal representative, P10’s case manager and P11’s case manager and maintain documentation of the review in P10’s and P11’s service recipient record; and · provide training to all staff that work with P10 and P11 on the IAPP and maintain documentation of this training in the personnel record, including the date the training is 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. 6. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P7, P8, and P9), the license holder did not provide written notice of service recipient rights as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder initiated services for P7 on July 3, 2023. The license holder did not provide P7 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. The license holder provided the written notice to P7 in July 2024. b. The license holder initiated services for P8 on February 1, 2023. The license holder did not provide P8 or P8’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights annually in 2024. The license holder provided P8 or P8’s legal representative with a notice of service recipient rights in November 2022 and August 2024. c. The license holder initiated services for P9 on August 5, 2024. The license holder did not provide P9’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P9’s legal representative 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 P9’s or P9’s legal representative’s receipt of a copy and an explanation the rights. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For two persons whose records were reviewed (P9 and P11), the license holder did not maintain documentation of how health needs would be met as required. a. The license holder was assigned the responsibility of medication administration to P9. The license holder did not maintain documentation on how P9's health needs would be met, including a description of the procedures the license holder would follow in order to provide P9 with medication administration. b. The license holder did not maintain documentation of how P11’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication setup, assistance or administration according to this chapter; · monitor health conditions according to written instructions from a license health professional; · assist with or coordinate medical, dental, and other health service appointments; or · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must: · add a description of the procedures you will follow in order to provide P9 with medication assistance; · provide training to all staff that work with P9 on this updated information and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; · include documentation in P11’s record on how the health needs will be met as outlined in (b); · provide training to all staff that work with P11 on this information and maintain documentation of this training in the personnel record including the date the training is 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. 8. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For four persons whose records were reviewed (P1, P2, P3, and P9), the license holder did not maintain documentation related to medication administration as required. a. The license holder did not ensure the following was documented in P1’s medication administration record (MAR) and readily available to all staff responsible for administering medication: · information on any risks or other side effects that are reasonable to expect, and any contradictions to its use; and · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. b. The license holder did not ensure the following was documented in P2’s medication administration record (MAR) and readily available to all staff responsible for administering medication: · information on any risks or other side effects that are reasonable to expect, and any contradictions to its use; · the possible consequences if the medication or treatment is not taken or administered as directed; and · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. c. The license holder did not ensure P3’s MAR included information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. d. The license holder did not obtain written authorization from P9 or P9’s legal representative to administer medication prior to administering medication. e. The license holder did not develop a MAR for P9 that included the following information: · the 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. This information must be readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. Corrective Action Ordered: Within 30 days of receiving this order, you must: · include the above-mentioned information in the MAR for P1, P2, P3, and P9; · ensure the information outlined above is readily available to all staff administering medication; and · obtain written authorization from P9 to administer medication. 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.05, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not review, and report medication and treatment issues as required. The license holder did not ensure the medication administration record was reviewed at least every three months to ensure that the information maintained in the medication administration record is current and to identify medication administration errors. Additionally, the license holder did not report to P2’s legal representative and P2’s case manager occurrences of P2 not receiving their medication as prescribed as they occurred. In June 2025, P2 did not receive their medication as prescribed for multiple days due to the license holder not ensuring the medication was available to be administered to P2. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review the last 3 months of medication administration records for P2 to ensure the information is current and correct and to identify any medication administration errors; · you must report to P2’s legal representative and P2’s case manager instances of P2’s refusal or failure to take or receive their medication or treatment as prescribed. Documentation of these notifications must be maintained in the service recipient record; and · develop a corrective action plan to ensure occurrences of medication not being administered as prescribed are reported to legal representatives and case managers as they occur. 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 Statutes, section 245D.071, subdivision 3, paragraph (a). Violation: For two persons whose records were reviewed (P10 and P11), the license holder did not complete initial intensive service planning as required. The license holder did not complete a preliminary support plan addendum for P10 and P11 within 15 calendar days of service initiation. Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For five persons whose records were reviewed (P3, P5, P9, P10, and P11), the license holder did not complete assessments as required. a. The license holder did not review assessments of P3’s ability to self-manage health and medical needs, personal safety, and symptoms or behavior as part of P3’s annual service plan review in 2022. b. The license holder did not conduct an assessment for P5 and P9 that included P5’s and P9’s overall strengths, functional skills and abilities, and behaviors or symptoms. c. The license holder did not complete assessments for P10 and P11 in the following areas: · P10’s and P11’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizure, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P10’s and P11’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 · P10’s and P11’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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an assessment of P5 that includes the requirements in (b); · review the results of the assessment with P5, P5’s legal representative, and P5’s case manager. Documentation of the review must be maintained in the service recipient record; · complete an assessment of P9 that includes the requirements in (b); · review the results of the assessment with P9, P9’s legal representative, and P9’s case manager. Documentation of the review must be maintained in the service recipient record; · complete assessments for P10 and P11 in the areas outlined above in (c) that produce information about P10’s and P11’s overall strengths, functional skills and abilities and behaviors or symptoms; · review the results of P10’s assessment with P10, P10’s legal representative and P10’s case manager. Documentation of the review must be maintained in the service recipient record; · review the results of P11’s assessment with P11, P11’s legal representative, and P11’s case manager. Documentation of the review must be maintained in the service recipient record; and · provide training to all staff that work with P5, P9, P10, and P11 on the results of the assessments and maintain documentation of this training in the personnel record including the date the training is 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. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Violation: For three persons whose records were reviewed (P9, P10, and P11), the license holder did not hold an initial planning meeting as required. a. P9’s service initiation for prevocational services and day support services was August 5, 2024. The license holder did not hold an initial planning meeting with P9, P9’s legal representative, and P9’s case manager, and other members of the support team or expanded support team within 45 days of service initiation to determine the following information based on P9’s assessments and support plan: · the scope of the services to be provided to support P9’s daily needs and activities; · P9’s desired outcomes and the supports necessary to accomplish those outcomes; · P9’s preferences for how services and supports are provided, including how the provider will support P9 to have control of P9’s schedule; and · opportunities to seek competitive employment and work at competitively paying jobs in the community. b. The license holder did not meet with P10, P10’s legal representative, P10’s case manager, and other members of the support team with 45 days of service initiation to determine: · the scope of the services to be provided to support P10’s daily needs and activities; · P10’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; · P10’s preferences for how services and supports are provided including how the provider would support P10 to have control over their schedule; · whether the current service setting is the most integrated setting available and appropriate for P10; and · how services must be coordinated across other providers licensed under this chapter serving P10 and members of the support team or expanded support team to ensure continuity of care and coordination of services for P10. c. The license holder did not meet with P11, P11’s legal representative, P11’s case manager and other members of the support team within 45 days of service initiation to determine: · the scope of the services to be provided to support P11’s daily needs and activities; · P11’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; · the person’s preferences for how services and supports are provided including how the provider will support P11 to have control over their schedule; · whether the current service setting is the most integrated setting available and appropriate for P11; and · how services must be coordinated across other providers licensed under this chapter serving P11 and members of the support team or expanded support team to ensure continuity of care and coordination of services for P11. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P9, P9’s legal representative, P9’s case manager, and other members of P9’s support team to determine the information outlined in (a); · meet with P10, P10’s legal representative, P10’s case manager, and other members of P10’s support team to determine the information outlined in (b); and · meet with P11, P11’s legal representative, P11’s case manager, and other members of P11’s support team to determine the information outlined in (c). 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.071, subdivision 3, paragraph (d). Violation: For four persons whose records were reviewed (P2, P9, P10, and P11), the license holder did not hold a discussion regarding technology as required. a. The license holder did not hold a discussion at the initial planning meeting with P2, P2’s legal representative, P2’s case manager, and other members of the support team on how technology might be used to meet P2’s desired outcomes. b. The license holder did not hold a discussion on how technology might be used to meet P9’s, P10’s, and P11’s desired outcomes including any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must: · hold a discussion with P9, P10, P11, P9’s legal representative, P10’s legal representative, P11’s legal representative, P9’s case manager, P10’s case manager, and P11’s case manager on how technology can be used to meet their desired outcomes; and · include a summary of this discussion in the support plan addendum including a statement regarding any decision made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. 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.071, subdivision 4. Violation: For four persons whose records were reviewed (P7, P9, P10 and P11), the license holder did not document service outcomes and supports as required. a. The license holder did not develop and document the following supports and methods to be implemented to support P7 and accomplish outcomes: · the methods or actions that would be used to support P7 and accomplish the service outcomes including information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment and materials required; and o techniques that were consistent with P7’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods.
b. The license holder initiated P9’s services on August 2, 2024. The license holder did not document the following supports and methods to be implemented to support P9 and accomplish outcomes: · the methods or actions that would be used to support P9 and to accomplish service outcomes including: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that were consistent with P9’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcomes had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. The license holder completed documentation that contained the information above in February 2025. c. The license holder did not develop and document the following supports and methods to be implemented to support P10 and accomplish outcomes: · the methods or actions that would be used to support P10 and to accomplish service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that were consistent with P10’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods. d. The license holder did not develop and document the following supports and methods to be implemented to support P11 and accomplish outcomes: · the methods or actions that would be used to support P11 and to accomplish service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that were consistent with P11’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and document the supports and methods to be used to support P7, P10, and P11 and to accomplish service outcomes; · submit the support plan addendum to P7, P10, P11, P7’s legal representative, P10’s legal representative, P11’s legal representative, P7’s case manager, P10’s case manager, and P11’s case manager and obtain dated signatures to document completion and approval of the support plan addendum; and · provide training to all staff that work with P7, P10, and P11 on the supports and methods developed for P7, P10, and P11. The documentation of this training must be maintained in the personnel record, including the date the training is 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. 15. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For five persons whose records were reviewed (P2, P3, P5, P6 and P7), the license holder did not complete service plan review and evaluation as required. a. The license holder did not hold a discussion in 2024 with P2, P2’s legal representative, P2’s case manager, and other members of P2’s support team on how technology might be used to meet P2’s desired outcome. b. The license holder did not hold a discussion in 2022, 2023, and 2024 with P3, P3’s legal representative, P3’s case manager, and other members of P3’s support team on how technology might be used to meet P3’s desired outcomes. c. The license holder did not meet with P5, P5’s legal representative, P5’s case manager, and other members of P5’s support team in 2024 to discuss the following: · how technology might be used to meet P5’s desired outcomes; · options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider; and · options for transitioning to an employment service. d. The license holder did not discuss with P6, P6’s legal representative, P6’s case manager, and other members of P6’s support team how technology might be used to meet P6’s desired outcomes in 2024. e. The license holder did not discuss with P7, P7’s legal representative, P7’s case manager, and other members of P7’s support team how technology might be used to meet P7’s desired outcomes in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · hold a discussion with P2, P2’s legal representative, P2’s case manager, other members of P2’s support team, P3, P3’s legal representative, P3’s case manager, and other members of P3’s support team on how technology might be used to meet P2’s and P3’s desired outcome; · summaries of the discussions held with P2 and P3 along with any decision made regarding technology and a description of any further research that needs to be completed before a decision regarding technology can be made must be included in the support plan addendum for P2 and P3; · hold a discussion with P5, P5’s legal representative, P5’s case manager, and other members of P5’s support team on: o how technology might be used to meet P5’s desired outcomes; o the options for P5 to transition out of a community setting not controlled by a provider; and o options for transitioning to an employment service; · a summary of this discussion held with P5, P5’s legal representative, P5’s case manager, and other members of P5’s support team, along with any decisions made regarding the use of technology, any decisions made regarding transitioning out of a provider controlled setting, and any decisions made regarding transitioning to an employment service must be included in P5’s support plan addendum; · hold a discussion with P6, P6’s legal representative, P6’s case manager, other members of P6’s support team, P7, P7’s legal representative, P7’s case manager, and other members of P7’s support team on how technology could be used to meet P6’s and P7’s desired outcomes; · summaries of the discussions held with P6 and P7 regarding the use of technology and a description of any further research that needs to be completed before a decision regarding technology can be made must be included in the support plan addendum for P6 and P7; and · submit to and obtain dated signatures from P2, P3, P5, P6, P7, P2’s legal representative, P3’s legal representative, P5’s legal representative, P6’s legal representative, P7’s legal representative, P2’s case manager, P3’s case manager, P5’s case manager, P6’s case manager, and P7’s case manager documenting approval of any changes to the support plan addendum. 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. 16. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P9), the license holder did not maintain a service recipient record as required. The license holder did not maintain progress or daily log notes that were recorded by the program for P9. Additionally, the license holder did not maintain a signed statement authorizing the license holder to act in a medical emergency when P9’s legal representative cannot be reached or is delayed in arriving. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain a signed statement for P9 authorizing you to act in a medical emergency when P9’s legal representative cannot be reached or is delayed in arriving; · maintain a copy of the signed authorization in P9’s service recipient record; and · begin maintaining progress or daily log notes that are recorded by the program for P9. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P9), the license holder did not inform and provide copies of policies as required. The license holder did not inform and provide copies of the following policies and procedures affecting P9’s rights to P9 or P9’s legal representative within five days of initiating prevocational and day support services: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy requirements. Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the above policies procedures affecting P9’s rights to P9 or P9’s legal representative. 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. 18. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For four persons whose records were reviewed (P6, P7, P10, and P11), the license holder did not develop and evaluate positive support strategies as required. a. The license holder did not evaluate the identified positive support strategies with P6 at least every six months. b. The license holder did not develop positive support strategies for P7, P10, and P11 and incorporate them in writing to an existing treatment, service or other individual plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · assess P7’s, P10’s, and P11’s strengths, needs, and preferences to identify and create positive support strategies for P7, P10, and P11; · incorporate the positive support strategies for P7, P10, and P11 in writing to an existing treatment, service, or other individual plan for P7, P10, and P11; and · provide training to all staff that work with P7, P10 and P11 on the positive support strategies and maintain documentation of this training in the personnel record including the date the training is 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. 19. Citation: Minnesota Rules, part 9544.0080, subparts 1 and 2. Violation: For one person whose record was reviewed (P9), the license holder did not obtain a written acknowledgement of the emergency use of manual restraint policy as required. The license holder did not obtain a written acknowledgement from P9’s legal representative indicating that P9 and P9’s legal representative had been notified of the license holders emergency use of manual restrains policy and procedure at service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain a written acknowledgement from P9’s legal representative that P9 and P9’s legal representative have been notified of your policy regarding the emergency use of manual restraints. 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. 20. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For four of twelve staff persons whose records were reviewed (SP2, SP3, SP4, SP5), the license holder did not ensure training to the program abuse prevention plan (PAPP) was completed as required. a. The license holder did not ensure that SP2 received an orientation to PAPP within 72 hours of first providing direct contact services. At the time of the review, SP2 had not received an orientation to the PAPP. b. The license holder did not ensure that SP3, SP4, and SP5 reviewed the PAPP annually in 2023, 2024, and 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide training to SP2, SP3, SP4, and SP5 on the program abuse prevention plan for the service sites SP2, SP3, SP4, and SP5 work at and maintain documentation of this training in the personnel record including the date the training is provided, the number of hours per subject area, and the name of the trainer or instructor; · conduct an audit of all staff records to identify staff that have not received orientation or annual training to the PAPP for the site they are assigned to work. For any staff that work at multiple locations, you must ensure they received orientation or training to the PAPP for each site they work at; · for any staff identified in the audit to not have received orientation or annual training to the PAPP, you must provide this training. For any staff identified that work at multiple locations, you must provide training to each site’s PAPP; · maintain documentation of this training in the personnel record, including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; and · maintain documentation of the audit, the results and corrective action in your program files for 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. 21. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not ensure completion of orientation as required. a. The license holder did not provide and ensure SP1 and SP2 completed training on 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 within 60 calendar days of hire. The license holder hired SP1 on May 6, 2025. At the time of the review, SP1 had not received orientation on service recipient rights. The license holder hired SP2 on February 14, 2023. SP2 received orientation on service recipient rights in April 2024. b. The license holder did not ensure SP2 completed training in basic first aid within 60 days of hire. The license holder hired SP2 on February 14, 2023, and provided SP2 with first aid training in August 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with training to the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 245D.04. Documentation of this training must be maintained in the personnel record including the date the training is 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. 22. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP3 and SP5), the license holder did not provide annual staff training as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder did not provide SP3 with training on the service recipient rights and staff responsibilities related to ensuring the protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 in 2023. SP3 received training on the service recipient rights in March 2022 and April 2023. b. The license holder did not provide SP5 with the following trainings annually: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act (HIPAA), and staff responsibilities related to complying with data privacy practices in 2022 and 2023; · the service recipient rights, and staff responsibilities related to ensuring the protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 in 2022, 2023, and 2024; · 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 service provided by SP5 in 2024; · the safe and correct use of manual restraints 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 in 2023; · 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 in 2023; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct an audit of personnel records to identify staff that have not completed orientation or annual training in the areas outlined in 245D.09, subdivisions 4 and 5; · for any staff identified to not have completed orientation or annual training in the required areas, you must provide and ensure completion of the missing training; · documentation of the training provided must be maintained in the personnel record, including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; and · maintain documentation of the audit, the results, and corrective action in your program files for 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. 23. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP5), the license holder did not maintain a personnel record as required. The license holder did not maintain a personnel record for SP1, SP2, and SP5 that included documentation of staff orientation and training including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Additionally, the license holder did not maintain a personnel record for SP2 that included documentation sufficient to determine the date of SP2’s first supervised direct contact and date of SP2’s first unsupervised direct contact with a person served by the program. Corrective Action Ordered: 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. 24. Citation: Minnesota Statutes, section 245D.22, subdivision 4, paragraph (b). Violation: The license holder did not ensure first aid kits at day service facilities were readily available on site as required. The license holder maintained first aid kits on site at day service facilities that were available for use by staff and persons receiving services. The license holder did not ensure the first aid kits contained first aid manuals and oral or surface thermometers. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure the first aid kits available for use by staff and persons receiving services include all required first aid supplies as outlined in 245D.22, subdivision 4, paragraph (b). 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. 25. Citation: Minnesota Statutes, section 245D.22, subdivision 5, paragraph (b). Violation: The license holder did not maintain emergency response documents as required. The license holder did not maintain a log of quarterly fire drills at the day service facilities as required. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a corrective action plan for ensuring quarterly fire drills are completed and documented at each day service location. You must submit to your licensor the corrective action plan for how quarterly fire drills will be performed and documented. 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. 26. Citation: Minnesota Statutes, section 245D.22, subdivision 7. Violation: The license holder did not maintain telephone numbers on site as required. The license holder did not ensure the following information was readily available to staff providing services at day service facilities: · names and telephone numbers of: o each individual’s legal representative; o physician, advanced practice registered nurse, or physician; and o dentist. Corrective Action Ordered: Within 30 days of receiving this order, you must audit person served records to ensure the above information for each individual is maintained and readily accessible to staff providing services. 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. 27. Citation: Minnesota Statutes, section 245D.29, subdivision 1. Violation: The license holder did not ensure proper refrigeration at the service sites as required. The license holder provided refrigeration at the day service facilities for storing perishable foods and perishable portions of bag lunches. The license holder did not ensure the refrigeration units maintained a temperature of 40 degrees Fahrenheit or less. Corrective Action Ordered: Immediately, you must ensure the refrigeration units used for storing perishable foods and perishable portions of bag lunches maintain a temperature of 40 degrees Fahrenheit or less. 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 erin.white1@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: Erin White 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Erin White, Home and Community Based Services Licensor Licensing Division Office of Inspector General 651-431-4821
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