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November 7, 2025 Bashe Said Siste, Authorized Agent MultiCare 1821 University Avenue West Suite 106 Saint Paul, Minnesota 55104-2810 License Number: 1098001 (245D – HCBS) CORRECTION ORDER Dear Bashe Said Siste: On August 8, 2025, a licensing review of MultiCare, located at 1821 University Avenue West, Suite 106, 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 1, paragraph (c). Violation: For five of five persons whose records were reviewed (P1-P5), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder did not provide P1-P5, with unknown dates of service initiation, with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of being admitted to the program. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1-P5 with an orientation to the above mentioned reporting procedures. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For four persons whose records were reviewed (P1, P3, P4, and P5), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required. The license holder did not provide P1, P3, P4, and P5 with an orientation to the program’s PAPP within 24 hours of admission. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1, P3, P4, and P5, and P1, P3, P4, and P5’s legal representative if applicable, with an orientation to your PAPP. You must maintain documentation that this orientation was provided in P1’s, P3’s, P4’s, and P5’s service recipient records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For five persons whose records were reviewed (P1-P5), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder did not develop an IAPP for P1-P5 as part of the initial program plan prior to initiating services that contained an individualized assessment of: · the person’s susceptibility to abuse by other individuals, including other vulnerable adults; · the person’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop an IAPP for P1-P5 that contains the above mentioned information; · provide P1’s-P5’s support teams an opportunity to participate in the review of the person’s IAPP and maintain documentation of this review; and · ensure all staff persons who provide direct support services to P1 and P2 receive an orientation to this plan and maintain documentation of this in the staff persons’ personnel file. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For five persons whose records were reviewed (P1-P5), the license holder did not provide service recipient rights as required. The license holder did not provide P1-P5 with a written notice that identifies the service recipient rights and an explanation of those rights within five working days of service initiation. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1-P5 with a written notice that identifies the service recipient rights and an explanation of those rights. You must maintain documentation that this was provided in the persons’ service recipient record. You must also provide a copy of these rights to P1-P5 annually. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not document health needs as required. P2’s support plan identified that the license holder was responsible for providing medication assistance and assistance with medical appointments. The license holder did not document a description of the procedures the license holder would follow in order to: · provide medication assistance to P2; and · assist with or coordinate medical, dental, and other health service appointments. Corrective Action Ordered: Within 60 days of receiving this order, you must document the above mentioned information in P2’s support plan addendum. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For five persons whose records were reviewed (P1-P5), the license holder did not ensure person centered planning and service delivery as required. The license holder did not ensure person centered planning and service delivery for P1-P5. At the time of the licensing review, the license holder had no service planning documents that identified P1’s – P5’s needs, interests, preferences, and desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must identify and document P1’s – P5’s needs, interests, preferences, or desired outcomes in P1’s – P5’s support plan addendums and ensure services are provided in response to P1’s-P5’s needs, interests, preferences, and desired outcomes. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (b). Violation: For two persons whose record was reviewed (P1 and P3), the license holder did not complete initial service planning for a basic service as required. a. The license holder did not develop a preliminary support plan addendum for P1 and P3 based on their support plan within 15 calendar days of service initiation. b. The license holder did not review and revise, as needed, the preliminary support plan addendums for P1 and P3 to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. Corrective Action Ordered: Within 60 days of receiving this order, you must develop support plan addendums for P1 and P3 that include the above mentioned information. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose record was reviewed (P2, P4, and P5), the license holder did not complete assessments and initial service planning for an intensive service as required. a. The license holder did not develop a preliminary support plan addendum for P2, P4, and P5 based on their support plan within 15 calendar days of service initiation. b. The license holder did not complete assessments in the following areas for P2, P4, and P5 before providing 45 days of service or within 60 calendar days of service initiation, whichever is shorter: · 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. c. The license holder did not hold an initial planning meeting with P2, P4, and P5, their legal representative if applicable, and P2, P4, and P5’s case managers before providing 45 days of service, or within 60 calendar days of service initiation, whichever is shorter, to determine the following: · the scope of the services to be provided to support the person's daily needs and activities; · the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; · the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and · how technology might be used to meet the person's desired outcomes. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a support plan addendum for P2, P4, and P5 based on their support plan; · complete the above mentioned assessments for P2, P4, and P5, as specified in part (b). The assessments must: o produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms; and o be based on the person's status within the last 12 months. Assessments based on older information must be documented and justified; · hold a service planning meeting for P2, P4, and P5 with their support team to determine the above mentioned information, as specified in part (c); · within 10 days of P2’s, P4’s, and P5’s service planning meetings, you must develop a service plan that documents the service outcomes and supports based on the assessments completed related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. The documentation must include: o the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person's communication mode and learning style; 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. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.081 Violation: The license holder did not complete program coordination, evaluation and oversight as required. a. The license holder did not ensure coordination of service delivery and evaluation of person served by the program, including the following, when the license holder did not have a person acting in the role of a designated coordinator: · oversight of the license holder's responsibilities assigned in the person's support plan and the support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the 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 designate a managerial staff person or persons to provide program management and oversight of the services provided by the license holder, including the following: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring 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); · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress toward accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; 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: · designate a staff person as your designated coordinator who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, as your designated manager, to provide program management and oversight of the services provided by the license holder; · ensure the person (s) you designate review and acknowledge their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and · maintain a signed document that the designated coordinator and designated manager have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records; and · submit the following to your licensor: o person(s) name and qualifications for your licensor to approve; and o the signed document that the person(s) you have designated have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 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.095, subdivision 3, paragraph (b). Violation: For five persons whose records were reviewed (P1-P5), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes recorded by the program for P1-P5. Corrective Action Ordered: Within 60 days of receiving this order, you must ensure that you are maintaining progress or daily log notes recorded by your program for each person who is receiving services. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraphs (a) and (b). Violation: For five persons whose records were reviewed (P1-P5), the license holder did not maintain a service recipient record as required. The license holder did not maintain the following information for P1-P5: · an admission form signed by the person or the person's legal representative that includes: o identifying information, including the person's name, date of birth, address, and telephone number; and o the name, address, and telephone number of the person's legal representative, if any, and a primary emergency contact, the case manager, and family members or others as identified by the person or case manager; · service information, including service initiation information, verification of the person's eligibility for services, documentation verifying that services have been provided as identified in the support plan or support plan addendum according to paragraph (a), and date of admission or readmission; · health information, including medical history, special dietary needs, and allergies, and when the license holder is assigned responsibility for meeting the person's health service needs according to section 245D.05: · current orders for medication, treatments, or medical equipment and a signed authorization from the person or the person's legal representative to administer or assist in administering the medication or treatments, if applicable; and · a medical appointment schedule when the license holder is assigned responsibility for assisting with medical appointments. Corrective Action Ordered: Within 60 days of receiving this order, you must maintain the above mentioned information in P’s1-P5’s service recipient records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.10, subdivision 1 Violation: The license holder did not establish, enforce, and maintain policies and procedures as required. The license holder did not maintain policies and procedures required in this chapter (245D), 245A, and other applicable state and federal laws governing the provisions of home and community-based services licensed according to this chapter when the license holder was unable to provide DHS licensors with the program’s policies at the time of the review. Corrective Action: Within 60 days of receiving this order you must establish, enforce, and maintain policies and procedures as required in this chapter, chapter 245A, and other applicable state and federal laws and regulations governing the provision of home and community-based services licensed according to this chapter. 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.10, subdivision 4, paragraph (b). Violation: For five persons whose records were reviewed (P1-P5), the license holder did not provide policies and procedures as required. The license holder did not provide P1-P5, or the persons’ case manager with copies of the following policies and procedures that affect a person’s rights within five working days of service initiation: · service suspension policy; · service termination policy; · grievance policy; and · emergency use of manual restraints policy. Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1-P5, and the persons’ case manager with copies of the above mentioned policies and procedures and maintain documentation that this was provided in the persons’ service recipient record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 14. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For five persons whose records were reviewed (P1-P5), the license holder did not develop positive support strategies as required. The license holder did not develop positive support strategies and incorporate them in writing to an existing treatment, service, or other individual plan for P1-P5. Corrective Action Ordered: Within 60 days of receiving this order, you must: · assess P1’s-P5’s strengths, needs, and preferences to identify and create positive support strategies for each person; and · incorporate the positive support strategies for P1-P5 in writing to an existing treatment, service, or other individual plan for the person. You must evaluate these positive support strategies with the person at a minimum of every six months. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For six of seven staff persons whose records were reviewed (SP1, SP2, and SP4-SP7), the license holder did not provide orientation training as required. The license holder did not provide orientation training to SP1, SP2, and SP4-SP7 on the following required topic areas within 60 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, 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 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 60 days of receiving this order, you must provide SP1, SP2, and SP4-SP7 with training on the above mentioned required topics. You must maintain documentation that the staff person received these trainings in their personnel file. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09 subdivision 4a. Violation: For six staff persons whose records were reviewed (SP1, SP2, and SP4-SP7), the license holder did not provide orientation on individual service recipient needs as required. The license holder did not provide SP1, SP2, and SP4-SP7, before having unsupervised contact with a person served by the program, with a review and instruction on the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and when applicable, the person's individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP1, SP2, and SP4-SP7 with orientation on the individual service recipient needs as described above. You must maintain documentation that this orientation was provided to SP1, SP2, and SP4-SP7 in the person’s personnel file. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For six staff persons whose records were reviewed (SP1, SP2, and SP4-SP7), the license holder did not maintain personnel records as required. The license holder did not maintain personnel records for SP1, SP2, and SP4-SP7 that included the following information: · the employee's date of hire, completed application, an acknowledgment signed by the employee that job duties were reviewed with the employee and the employee understands those duties, and documentation that the employee meets the position requirements as determined by the license holder; and · documentation of staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, 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: Within 60 days of receiving this order, you must create a personnel record for SP1 and SP2-SP7 that includes the above mentioned information. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance throughout your program, 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 Rebecca.DeYonge@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: Rebecca DeYonge 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. Rebecca DeYonge, Human Services Licensor Licensing Division Office of Inspector General 651-431-6351
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