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November 19, 2025 Timothy Osmondson, Authorized Agent Jobs House of Prosperity 7581 9 Street North Suite 100 Oakdale, Minnesota 55128-6635 License Number: 1103884 (245D – HCBS) 1124560 (CRS) 1124731 (CRS) 1123830 (CRS) Investigation Number: 202504748 CORRECTION ORDER Dear Timothy Osmondson: On September 9, 2025, through September 11, 2025, a licensing review and licensing investigation of Jobs House of Prosperity, located at 7581 9 Street North, Suite 100, Oakdale, 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 and licensing investigation, a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For seven of nine persons whose record was reviewed (P1-P6, and P8), the license holder did not establish and provide an orientation to the program abuse prevention plan (PAPP) as required. a. The license holder did not provide P1, P3-P6, and P8 with an orientation to the PAPP with 24 hours of admission. The license holder maintained a document in P1’s, P3’-P6’s and P8’s support plan addendums titled, “Policy Orientation Receipt.” The license holder documented “NA” for the orientation to the PAPP on this document. b. The license holder provided crisis respite to P2 at a location that was within the control of the license holder. The license holder did not establish a written PAPP that assessed the population, the physical plant, and the environment within the control of the license holder and the location where licensed services were provided. Corrective Action Ordered: P1, and P5 no longer receive services from the license holder. P2 no longer receives crisis respite services from the license holder. Within 30 days of receiving this order, you must: · provide P3, P4, P6, and P8 with an orientation to the PAPP; · notify the person’s legal representative, if applicable, of this orientation; and · maintain documentation of this orientation in P3’s, P4’s, P6’s, and P8’s support plan addendums. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For four persons whose records were reviewed (P3, P5, P6, and P8), the license holder did not meet the requirements for individual abuse prevention plans (IAPP) as required. a. The license holder initiated P3’s services on June 17, 2024. The license holder did not develop an IAPP as part of the initial individual program plan or service plan prior to or upon service initiation. The license holder developed P3’s IAPP on December 12, 2024. b. The license holder did not develop IAPPs for P5, P6, and P8 that included a statement of measures that would be taken to minimize the risk of abuse to P5, P6, and P8 within the scope of licensed services. Corrective Action Ordered: P5 no longer receives services from the license holder. Within 30 days of receiving this order you must: · revise the IAPPs for P6 and P8 to include the information that meets the requirements of this section; · review P6’s IAPP with P6, P6’s legal representative, and P6’s case manager; and · review P8’s IAPP with P8, P8’s legal representative, and P8’s case manager. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For four persons whose records were reviewed (P1, P3, P7, and P8), the license holder did not provide or inform the person or the person’s legal representative of the identified service recipient rights in subdivisions 2 and 3 and an explanation of those rights annually 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 provide P1, P3, P7, P8, or their legal representatives, if applicable, with a written notice that identifies the service recipient rights and an explanation of those rights annually. · The license holder provided P1’s legal representative with the written notice on July 30, 2024, and August 20, 2025. · The license holder provided P3 with the written notice on June 20, 2024, and July 31, 2025. · The license holder most recently provided P7’s legal representative with a written notice on August 16, 2023. · The license holder provided P8 with the written notice on May 31, 2024, and August 14, 2025. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must provide a written notice that identifies the service recipient rights and an explanation of those rights to P7 or P7’s legal representative. You must maintain documentation of this in P7’s support plan addendum. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For seven persons whose records were reviewed (P1, P3-P6, and P8), the license holder did not ensure the protection of persons rights and did not document or review the need for the rights restriction as required. a. The license holder implemented several rights restrictions for P1 on August 5, 2024. The license holder did not review the need for the rights restrictions based on the conditions for ending the rights restrictions semiannually from the date of approval. The initial approval for P1’s rights restrictions was August 4, 2024, and the license holder reviewed the need for P1’s rights restrictions in March 2025. b. The license holder implemented a rights restriction for P3 on June 17, 2024. The license holder did not review the need for the rights restriction based on the conditions for ending the restriction semiannually from the date of initial approval. The license holder reviewed the need for the rights restriction on December 12, 2024, and July 31, 2025. c. The license holder maintained documentation in P3’s support plan addendum for a restriction of P3’s right to access their lighter at any time. The license holder did not document the objective measures set as conditions for ending the restriction. d. The license holder maintained documentation in P6’s support plan addendum restricting P6’s rights to access their personal possessions including financial resources and to have private access to use of a telephone. The license holder did not document the objective measures set as conditions for ending the restriction. e. The license holder did not ensure the exercise and protection of P4’s and P6’s right to have free access to common areas in the residence when P4 and P6 resided in community residential settings (CRS, license numbers 1124560 and 1124731) operated by the license holder. On September 11, 2025, DHS licensors observed the laundry rooms were locked and were not freely accessible to P4 and P6. f. The license holder documented two rights restrictions for P8 that included limiting personal privacy and limiting access to P8’s personal possessions. The license holder did not document objective measures set as conditions for ending the restriction and did not implement the rights restriction in the least restrictive manner necessary to protect P8. g. P8 resided in a CRS (license number 1123830) operated by the license holder. The license holder did not ensure P8’s access to three nutritionally balanced meals and nutritious snacks between meals each day and did not provide P8 with the right to freedom and support to access food at any time. Licensors observed minimal food items in the refrigerator and pantry. There was a small refrigerator located in the locked staff office that was not accessible to P8 without staff assistance and did not contain food items needed for a balanced and nutritious diet. h. The license holder did not ensure the exercise of service recipients right to have access to personal possessions and chosen activities when the license holder did not allow service recipients to have any alcohol at all service sites. Corrective Action Ordered: P1 no longer receives services from the license holder. Immediately upon receipt of this order, you must: · ensure the exercise and protection of service recipient rights to participate in chosen activities and to have access to personal possessions at all service sites; · restore P4’s and P6’s right to have use and free access to common areas in the residence; · ensure P8’s access to three nutritionally balanced meals and nutritious snacks in between meals. Within 30 days of receiving this order, you must: · meet with P3, P3’s legal representative, P3’s case manager, and other members of P3’s support team to determine the objective measures set as conditions for ending the restriction. You must maintain documentation of this in P3’s support plan addendum; · meet with P6, P6’s legal representative, P6’s case manager, and other members of P6’s support team to determine the objective measures set as conditions for ending the restriction. You must maintain documentation of this in P6’s support plan addendum; · meet with P8, P8’s legal representative, P8’s case manager, and other members of P8’s support team to determine the objective measures set as conditions for ending the restriction. You must maintain documentation of this in P8’s support plan addendum; and · review rights restrictions at least semi-annually to ensure that they reflect the least restrictive manner necessary to ensure the health and safety of P3 and P8. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For four persons whose records were reviewed (P1, P2, P4, and P6), the license holder did not document health service needs as required. a. The license holder was assigned responsibility for 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 monitor health conditions and use medical equipment, including P1’s oxygen tank. b. The license holder was assigned responsibility for meeting P1’s, P2’s, P4’s and P6’s health needs. The license holder did not maintain documentation on how P1’s, P2’s, P4’s and P6’s health needs would be met including a description of the procedures the license holder would follow in order to provide medication administration according to this chapter, including how to administer P1’s, P2’s , P4’s and P6’s pro re nata (PRN) psychotropic medications. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must maintain a description of how P2’s, P4’s and P6’s health needs will be met as mentioned above. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For six persons whose records were reviewed (P1, P2, P3, P4, P5, and P8), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for medication administration for P1. The license holder did not ensure P1 took medications as prescribed in the following: · P1 was prescribed a seven day course of medication on January 31, 2025. The license holder did not document that this medication was ever administered to P1. · P1 was prescribed an ointment to be applied daily. The license holder stopped administering the ointment daily to P1 on January 17, 2025. The license holder did not administer the ointment as prescribed from January 2025 to July 2025. b. The license holder was assigned responsibility for medication administration for P2. P2 was prescribed a medication that required the license holder to contact the prescriber each month to refill the medication. The license holder did not implement medication administration procedures to ensure P2 took medications as prescribed when the license holder did not contact the prescriber timely, and the medication was not available to be administered from February 6, 2025, to February 8, 2025. c. The license holder was assigned responsibility for medication administration for P2, P3, P4, and P5. The license holder did not notate the following in the medication administration record (MAR): · when medications were administered to P2 on various dates from January 2025 to March 2025; · when medications were administered to P3 on various dates from February 2025 to July 2025; · when medications were administered to P4 on various dates from October 2024 to December 2025; and · when medications were administered to P5 on various dates in March 2025.
d. The license holder did not ensure the following was documented in P5’s and P8’s MARs: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use; · instruction on when and to whom to report if a dose of medication was not administered or treatment performed as prescribed and the occurrence of possible adverse reactions to the medication or treatment; and · the possible consequences if the medication or treatment is not taken or administered as directed.
7. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For four persons whose records were reviewed (P1, P2, P3, and P8), the license holder did not review, and report medication and treatment issues as required. a. The license holder did not complete MAR reviews for P1 at least every three months. Additionally, the license holder did not notify P1’s legal representative and case manager of P1’s refusal to take medication as prescribed as the refusal occurred. P1 frequently refused to take medications, and the license holder did not report all refusals to P1’s legal representative and case manager. b. The license holder did not report medication errors to P2’s case manager and legal representative. P2 was not administered a medication from February 6, 2025, to February 8, 2025, because the medication was not available, and the license holder did not report this to P2’s legal representative and P2’s case manager. c. The license holder did not complete an accurate MAR review for P2 when the license holder indicated there were no medication administration errors between January 2025 to March 2025 in the MAR review dated April 2, 2025. DHS licensors identified 3 medication administration errors for the same time span. d. The license holder maintained a MAR review, dated October 10, 2024, that indicated P3 refused medication on September 12, 2024. The license holder did not notify P3’s legal representative and case manager of P3’s refusal to take medication as prescribed as the medication refusal occurred. e. The license holder did not complete MAR reviews for P8 every three months. There were no MAR reviews recorded from April 2025 to the date of the licensing review for P8. Additionally, the license holder did not notify P8’s legal representative and case manager when P8 did not receive their medication as prescribed on various dates from April 2025 to August 2025. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must: · report the medication errors listed above to P2’s legal representative and P2’s case manager; · report P3’s medication refusal to P3’s legal representative and case manager; and · maintain documentation of the notification to P2’s legal representative and case manager in P2’s support plan addendum, and notification to P3’s legal representative and case manager in P3’s support plan addendum. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For seven persons whose records were reviewed (P1, P2, P3, P4, P5, P6, and P8), the license holder did not meet the requirements for psychotropic medication use and monitoring as required. Target symptoms refer 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 responsibility for administering P1’s - P6’s, and P8’s psychotropic medications in their support plan addendums. The license holder did not maintain documentation with the description of the target symptoms that each of P1’s - P6’s, and P8’s psychotropic medications were intended to alleviate in their support plan addendum. Corrective Action Ordered: P1, and P5 no longer receive services from the license holder. Within 30 days of receiving this order, you must maintain documentation with the description of the target symptoms that P2’s, P3’s, P4’s, P6’s, and P8’s psychotropic medications are to alleviate in the person’s support plan addendum. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.06, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P8), the license holder did not report incidents as required. a. The license holder did not report incidents involving P1 to P1’s legal representative and case manager within 24 hours of the incident occurring for incidents that occurred in October 2024, April 2025, and June 2025. b. The license holder did not report an incident involving P8 that occurred on February 15, 2025, to P8’s legal representative and case manager within 24 hours of the incident occurring. c. The license holder did not conduct an internal review of incident reports involving P8 on September 15, 2024, and February 15, 2025, that included information on whether or not additional staff training was needed. Corrective Action Ordered: P1 no longer receives services from the license holder. Within 30 days of receiving this order, you must complete the internal reviews for the incidents above and maintain documentation of the information identified in letter (c) for P8. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required. 10. Citation: Minnesota Statutes, section 245D.06, subdivision 5, and Minnesota Rule 9544.0060, subpart 2, item C. Violation: For two persons whose records were reviewed (P8 and P9), the license holder did not prohibit the use of prohibited procedures as a behavioral or therapeutic program to reduce or eliminate behavior as required. a. The license holder did not prohibit the use of a prohibited procedure for P8. The license holder implemented a mechanical restraint, a prohibited procedure, on P8 on September 15, 2024, when a staff person held P8’s seatbelt so that P8 could not unbuckle and leave the vehicle. b. The license holder did not ensure the use of manual restraints were prohibited. The license holder implemented a manual restraint on P8 on April 15, 2024, that did not meet the conditions for emergency use of manual restraint when P8 or others were not at imminent risk of physical harm. c. Regarding investigation number 202504748, the license holder documented on April 18, 2025, that P9 attempted to grab at SP10 from the back. SP10 was able to get out of the grab and implemented a manual restraint on P9. The license holder did not ensure the use of manual restraints were prohibited, when the license holder implemented a manual restraint on P9 that did not meet the conditions for emergency use of manual restraint when P9 or others were not at imminent risk of physical harm. Additionally, the license holder did not prohibit speaking to P9 in a manner that was threatening prior to SP10 implementing the manual restraint. Corrective Action Ordered: P9 no longer receives services from the license holder. Immediately upon receiving this order, you must prohibit the use of prohibited procedures in your program. Within 30 days, you must provide all staff members retraining on prohibited procedures. You must maintain documentation of this training in staff persons personnel records. Compliance with this subdivision will be monitored onsite at an upcoming licensing review. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.06, subdivision 8. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not develop and review the positive support transition plan (PSTP) in the manner prescribed by the commissioner as required. a. The license holder developed a PSTP for P1 on the forms prescribed by the commissioner. The form prescribed by the commissioner requires that the expanded support team review the effectiveness of the PSTP no less than every quarter (or 90 days). The license holder did not complete the quarterly reviews of P1’s PSTP. b. The license holder did not develop P4’s PSTP in the manner prescribed by the commissioner. The license holder did not submit the PSTP they developed for P4 within 30 days after the PSTP’s implementation date to DHS. Additionally, the license holder did not submit the quarterly reviews of P4’s PSTP within 30 days after the quarterly review was completed to DHS. Corrective Action Ordered: P1 no longer receiving services from the license holder. Within 30 days of receiving this order, you must submit P4’s PSTP and quarterly reviews to DHS in the manner prescribed the commissioner. Compliance with this subdivision will be monitored onsite at an upcoming licensing review. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: For one person whose record was reviewed (P9), the license holder did not implement the emergency use of manual restraint policy as required. a. The license holder’s EUMR policy allowed for the emergency use of manual restraints. The license holder did not implement the license holder’s EUMR policy when P9 was involved in an incident on April 18, 2025, where P9’s behavior posed an imminent risk of physical harm to self. P9 banged their head on a staff person’s vehicle window and the license holder did not implement an EUMR to protect the health and welfare of P9 when P9 was at imminent risk of physical harm. b. The license holder’s EUMR policy identified three allowed manual restraint procedures staff could utilize. The license holder did not follow the license holder’s EUMR policy on April 18, 2025, when SP10 implemented a manual restraint on P9 that was not allowed according to the license holder’s EUMR policy. Corrective Action Ordered: P9 no longer receives services from the license holder. Within 30 days, you must provide all staff members retraining on the license holder’s EUMR policy and procedures. You must maintain documentation of this training in staff persons personnel records. Compliance with this subdivision will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For three persons whose records were reviewed (P2, P5, and P7), the license holder did not provide services in compliance with the requirements of the federal waiver plan as required. a. The license holder did not provide services in response to P2 identified supervision needs as specified in P2’s support plan and support plan addendum. P2’s support plan assigned the license holder to provide 2 staff to supervise P2 at all times. The license holder did not provide the assigned supervision to P2 on May 18, 2025, June 1, 2025, June 2, 2025, and June 15, 2025. b. The license holder did not provide services in response to P5’s needs as assigned in P5’s support plan. The license holder maintained a disability waiver rate system (DWRS) exception document in P5’s record that indicated staff working with P5 needed to meet the following qualifications or additional training: · minimum of two years’ experience with a related educational background, such as an associate’s degree, or one year experience with a bachelor’s degree; and · experience working with individuals with mental health behaviors and symptoms. The license holder did not ensure that staff met these qualifications. SP6 worked with P5. SP6’s personnel record included information that SP6 did not have any experience providing direct support to individuals with disabilities and mental health needs. c. The Community-Based Services Manual (CBSM) page titled “Paying relatives and legally responsible individuals” states that relatives cannot be paid to provide individualized home supports with family training services. The license holder provided individualized home supports with family training services to P7. P7's parent was employed by the license holder and provided this service to P7. The license holder did not provide services according to the requirements of the federal waiver plan when the license holder provided individualized home supports with family training to P7 and P7's parent provided the service. Corrective Action Ordered: P5 no longer receive services from the license holder. Immediately, you must comply with the requirements of the federal waiver plan. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P3, P4, and P5), the license holder did not meet initial service planning requirements as required. a. The license holder did not complete assessments that produced information about P3 and P5 that described the person’s overall strengths, functional skills, and abilities. b. The license holder did not accurately document the scope of services in P3’s support plan addendum. The license holder provided community residential services to P3. The license holder documented that the license holder provided crisis respite services to P3. c. The license holder did not complete assessments that produced information about P4 that described P4’s overall strengths, functional skills and abilities and behaviors or symptoms. d. The license holder did not have a discussion of how technology might be used to meet P4’s desired outcomes at P4’s initial service planning meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise the required assessments for P3 and P5 to ensure the assessments produce information about the person that describes the person’s s overall strengths, functional skills, and abilities; · review the assessments with P3, P3’s case manager and members of P3’s support team, and with P4, P4’s legal representative, and P4’s case manager and members of P4’ssupport team; · document the review in P3’s and P4’ssupport plan addendums; · discuss with P4, P4’s case manager, and members of P4’s support team about how technology might be used to meet the person’s desired outcomes; and · document a summary of this discussion in P4’s support plan addendum that includes the following: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P4), the license holder did not develop service outcomes and supports as required. The license holder did not develop supports and methods to be implemented to support P4 to accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. The documentation must include the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about any changes or modifications to the physical and social environments necessary when the service supports are provided. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop supports and methods for P4’s desired outcomes including the information detailed above; · submit to P4’s legal representative and P4’s case manager for approval; · provide orientation to P4’s documented supports and methods to all staff who provide direct support services to P4; and · implement the supports and methods for P4’s desired outcomes and track data related to their outcomes. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not complete service plan review and evaluation as required. a. The license holder did not summarize P3’s progress toward achieving the identified outcome, make recommendations, and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in a written report at least annually. b. The license holder maintained documentation in P4’s support plan addendum that required semi-annual written reports regarding P4’s progress or status. The license holder did not provide written reports to P4’s expanded support teams on semi-annual basis. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete written reports for P3 and P4 that is relative to their most recent progress review meetings. The written reports must include recommendations and identify the rationale for changing, continuing or discontinuing implementation of supports and methods; and · provide the reports to P3’s and P4’s support teams. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.
17. Citation: Minnesota Statutes, section 245D.06, subdivision 8. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not review the positive support transition plan (PSTP) as required. a. The license holder developed a PSTP for P1 on the forms prescribed by the commissioner. The form prescribed by the commissioner requires that the expanded support team reviews the effectiveness of the PSTP no less than every quarter (or 90 days). The license holder did not complete the reviews of P1 b. The license holder did not develop P4’s PSTP in the manner prescribed by the commissioner. The license holder did not submit the PSTP they developed for P4 within 30 days after the PSTP’s implementation date to DHS. Additionally, the license holder did not submit the quarterly reviews of P4’s PSTP within 30 days after the quarterly review was completed. Corrective Action Ordered: P1 no longer receiving services from the license holder. Within 30 days of receiving this order, you must submit P4’s PSTP and quarterly reviews to DHS in the manner prescribed by the commissioner. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For four of twelve staff persons whose records were reviewed (SP3-SP6), the license holder did not provide orientation training as required. a. The license holder did not provide orientation to SP3 on the following within 60 days of hire: · license holder’s current policies and procedures including their location and access, and staff responsibilities related to the implementation of those policies and procedures, including: o temporary service suspension policy; o service termination policy; and o service admission policy; · the license holder’s program abuse prevention plan; and · basic first aid. a. SP4 was hired on November 17, 2023. The license holder did not provide orientation to SP4 on the following within 60 days of hire: · license holder’s current policies and procedures including their location and access, and staff responsibilities related to the implementation of those policies and procedures, including: o temporary service suspension policy; o service termination policy; and o service admission policy; and · the license holder’s program abuse prevention plan. · service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04. SP4 was provided this training on September 4, 2024; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. SP4 received this training on September 8, 2024. b. SP5 was hired on December 12, 2024. The license holder did not provide orientation to SP5 on the following within 60 days of hire: · license holder’s current policies and procedures including their location and access, and staff responsibilities related to the implementation of those policies and procedures, including: o temporary service suspension policy; o service termination policy; and o service admission policy; · the license holder’s program abuse prevention plan; · service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section SP5 received this training on July 14, 2025; · the safe and correct use of manual restraint on an emergency basis and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. SP5 received this training on July 13, 2025; · and 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. SP5 received this training on July 13, 2025; · 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. SP5 received this training on July 15, 2025. b. The license holder did not provide orientation to SP6 on the following within 60 calendar days of hire on the following: · license holder’s current policies and procedures including their location and access, and staff responsibilities related to the implementation of those policies and procedures, including: o temporary service suspension policy; o service termination policy; o service admission policy; and · the license holder’s program abuse prevention plan. c. SP4, SP5, and SP6 worked with persons served who required that staff be trained in CPR. The license holder did not provide CPR training to SP4, SP5, and SP6. Corrective Action Ordered: SP6 is no longer employed by the license holder. Within 30 days of receiving this order, you must provide orientation to SP3, SP4, and SP5 to the areas listed above. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (d). Violation: For two staff persons whose records were reviewed (SP4 and SP5), the license holder did not provide instruction on medication administration as required. The license holder did not provide medication administration training to SP4 and SP5 that incorporated an observed skill assessment to ensure that SP4 and SP5 demonstrated the ability to safely and correctly follow medication procedures. Corrective Action Ordered: Within 30 days of receiving this order, you must provide medication administration training to SP4 and SP5 that includes an observed skill assessment. You must document this training in SP4’s and SP5’s personnel records. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 20. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP3-SP4), the license holder did not provide annual staff training as required. a. The license holder did not provide SP3 annual training on the following topics: · data privacy requirements according to MN Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 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; · 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 annual training on the following to SP4 in 2024: · emergency use of manual restraint on an emergency basis; and · basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, you must provide training to SP3 on the topics mentioned above and document the training in SP3’s personnel record. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 21. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (3). Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not maintain service recipient records as required. The license holder did not protect P1’s and P5’s service recipient records from loss when the license holder did not maintain part of P1’s and P5’s medication administration records. Corrective Action Required: P1 and P5 no longer receive services from the license holder. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 22. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder did not ensure the staff person the license holder identified as designated coordinators (SP2, SP14-SP20) provided coordination of service delivery and evaluation for each person served by the program that included: · oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder did not ensure the staff persons the license holder identified as the designated managers (SP1, SP11-SP13) provided program management and oversight of the services provided by the license holder that included: · maintain 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 (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · 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 towards 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. c. The license holder identified SP1 as a designated manager. The license holder did not ensure that SP1: · met the minimum education, work experience requirements for the designated coordinator as identified in subdivision 2, paragraph (b); and · had a minimum of three years of supervisory level experience in a program providing direct support services to persons with disabilities or age 65 and older, as required for the designated manager. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a signed documented that the designated coordinators and designated managers have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records. · develop and implement a written plan for how you will come into compliance in all areas listed in this correction order. This plan must include specific actions you will implement to ensure ongoing compliance with the 245D requirements throughout your program on an ongoing basis; and · submit the plan to your licensor. Compliance with this subdivision will be monitored onsite. 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 lacey.l.walsvik@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: Lacey Walsvik 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. Lacey Walsvik, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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