|
November 20, 2025 CERTIFIED MAIL Debra and Matthew Hellwege 2077 Copper Lane Eagan, Minnesota 55122 License Number 1078723 (AFC) 1080422 (245D – HCBS) ORDER OF CONDITIONAL LICENSE Dear Debra and Matthew Hellwege: Based on the recommendation from Dakota County Community Services, the Department of Human Services (DHS) is placing your licenses to provide family adult foster care and home and community-based services at 2077 Copper Lane, Eagan, Minnesota on conditional status for two years, beginning November 20, 2025. This means you must meet certain conditions to maintain your licenses, detailed below. This order applies to the service sites detailed in the “Applicability of Conditional License” section below. This order is based on your level of noncompliance with family adult foster care and home and community-based licensing requirements. Our next steps and your options are also provided below. REASON FOR THE CONDITIONAL LICENSE 1. Failure to comply with licensing laws and rules As a result of licensing investigation from January 2025, Dakota County determined that your program failed to comply with the laws and rules for licensed family adult foster care. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1. AFC LICENSING VIOLATIONS From January 2025 to April 2025, Dakota County conducted a licensing investigation at your licensed program. The following are new violations that have not been the subject of a previous correction order. If you request reconsideration of this order, the following violations may be reviewed as a part of the reconsideration. DHS considered these violations as a factor when it determined that a Conditional License is appropriate. 1. Violation: Dakota County determined that you did not provide primary care to the residents in your home based on interviews, medication records, and time sheets. Statute Violated: Minnesota Statutes, section 245A.02, subdivision 6f. HCBS LICENSING VIOLATIONS DHS conducted a licensing review on January 6, 2025, and determined that your program did not follow licensing rules and statutes, as described below. The following are new violations that have not been the subject of a previous correction order. If you request reconsideration of this order, the following violations maybe reviewed as a part of the reconsideration. DHS considered these violations as a factor when it determined that a Conditional License is appropriate. Program Coordinator and Management Violation 2. Violation: The license holder did not ensure the designated coordinator and the designated manager (SP4), provided program management and oversight of the services provided by the license holder as required. a. The license holder did not ensure that the designated coordinator (SP4), provided supervision, support, and evaluation of activities that included: · provide oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · take the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · provide 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; and · evaluate 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 outcomes has been achieved according to the requirements in section 245D.07. b. The license holder did not ensure that the designated manager (SP4), provided program management and oversight of the services provided by the license holder that included: · maintain 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; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluate the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations two through twenty-three for the designated coordinator and designated manager’s failure to provide the above stated requirements. Corrective Action Ordered: Within 30 days of receiving this order, you must complete the actions required in Term number 2 of this order. On an ongoing basis, you must ensure the program’s designated coordinator and designated manager fulfill their responsibilities of program coordination, management and oversight as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. Service Recipient Violations 3. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for funds and property as required. The license holder was responsible for safekeeping P1’s and P2’s personal funds and property. The license holder stated that when P1 and P2 need to make a purchase, the license holder expensed it. The license holder did not ensure separation of funds of persons served by the program from funds of the license holder, the program, or program staff. Corrective Action Ordered: Immediately upon receiving this order, you must: · separate P1’s and P2’s personal funds from the funds of the license holder, the program or program staff; and · begin documenting receipt and disbursement of P1’s and P2’s funds or other property at the time of receipt or disbursement. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13. 4. Violation: For one person whose record was reviewed (P2), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults and the program abuse prevention plan (PAPP) as required. a. The license holder did not provide P2 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. b. The license holder did not provide an orientation to P2 to the PAPP within 24 hours of admission. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide an orientation to the internal and external reporting procedures and the program’s PAPP to P2; · notify P2’s legal representative of the orientation; and · maintain documentation of this orientation in P2’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). 5. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop, and review abuse prevention plans as required. a. The license holder did not review the individual abuse prevention plan for P1 annually in 2023 and 2024. The license holder only maintained the individual abuse prevention plans that the license holder developed for P1 and P2 in 2022. b. The license holder assessed P1 and P2 to be susceptible to sexual abuse, physical abuse, self-abuse and financial exploitation. The license holder did not list specific measures that would be taken to minimize the risk of abuse for any of the areas where it was assessed that P1 and P2 were susceptible to abuse in P1’s and P2’s individual abuse prevention plans.
Corrective Action Ordered: Within 60 days of receiving this order, you must review and revise P1’s and P2’s individual abuse prevention plans to include a statement of the specific measures that would be taken to minimize the risk of abuse for each assessed area of risk of abuse. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 6. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the 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 did not provide a written notice that identifies the service recipient rights and an explanation of those rights to P1 or P1’s legal representative annually in 2023 or 2024. The license holder only provided P1 or P1’s legal representative with a written notice in May 2022. b. The license holder did not provide a written notice that identifies the service recipient rights and an explanation of those rights to P2 or P2’s legal representative annually in 2023 or 2024. The license holder provided P2 or P2’s legal representative with a written notice in October 2022, and November 2023. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide P1 and P2 with a copy of the service recipient rights and an explanation of those rights; · maintain documentation of the receipt of the rights; and · submit a copy of this receipt to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 7. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain documentation of how the person’s health needs would be met as required. a. The license holder was assigned the responsibility of meeting P1’s health service needs. The license holder did not document a description of the procedures for P1 that the license holder will follow in order to provide medication setup, assistance, or administration according to this chapter. b. The license holder was assigned the responsibility of meeting P1’s and P2’s health service needs. The license holder did not maintain documentation on how P1’s and P2’s health needs would be met, including as applicable, a description of the procedures the license holder will follow in order to: · monitor health conditions according to written instructions from a licensed 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 60 days of receiving this order, you must document the above mentioned information in P1’s and P2’s support plan addendums. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1. 8. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain medication administration records as required. a. The license holder provided medication administration to P1 and P2. The license holder did not document the following in P1’s and P2’s medication administration records: · information on any risks or other side effects that are reasonable to expect, including any contraindications; · possible consequences if the medication or treatment is not taken as directed; · information on when and to whom to report: o if a dose of medication or treatment is not administered or treatment is not performed as prescribed, whether by error of the staff or P1 or by refusal by P1; o the occurrence of possible adverse reactions to the medications or treatment. b. P2 was prescribed a course of medication to be taken twice daily for seven consecutive days during the month of January 2025. The license holder did not document a notation on P2’s medication administration record when this medication was started or discontinued. Corrective Action Ordered: Within 60 days of receiving this order, you must document the above mentioned information in P1’s and P2’s medication administration records. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on February 13, 2019, you were previously found in violation of this same statute. 9. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for safekeeping of funds and property as required. The license holder did not obtain written authorization from P1’s legal representative and P1’s case manager, and P2’s legal representative and P2’s case manager for the safekeeping of funds and property within five working days of service initiation. Corrective Action Ordered: Within 60 days of receiving this order, you must: · obtain written authorization from P1’s and P2’s legal representatives and case managers to assist P1 and P2 with the safekeeping of P1’s and P2’s funds and property; · survey, document, and implement the preferences of P1’s and P2’s legal representatives and case managers for frequency of receiving a statement that itemizes receipts and disbursements of funds or other property; and · maintain this documentation in P1’s and P2’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 4. 10. Violation: For one person whose record was reviewed (P2), the license holder implemented a prohibited procedure. The license holder did not prohibit the use of a mechanical restraint when the license holder developed a procedure for P2 on December 27, 2024, that implemented the use of a mechanical restraint. The procedure documented staff were to duct tape a sock or oven mitt to P2’s hands if P2 engaged in self-injurious behaviors during the day and to duct tape a sock or oven mitt to P2’s hands at night. Corrective Action Ordered: Immediately upon receiving this order, you must stop the use of the mechanical restraint. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 5. 11. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete and reviews assessments for an intensive service as required. The license holder did not complete assessments in the following areas for P1 within 45 days of providing service. Additionally, the license holder did not complete the assessments on an annual basis for P1 and P2 in 2023 and 2024: · 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 accident 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. The assessments must produce information about the person that describes the person’s overall strengths, functional skills and abilities, and behaviors or symptoms. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete the above mentioned required assessments for P1 and P2; · provide P1 and P2, their legal representatives, and case managers with an opportunity to review the results of these assessments; and · maintain documentation that this review occurred. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 12. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet initial service planning requirements for an intensive service. a. The license holder did not hold initial service planning meetings for P1 and P2 with the person’s legal representative, the person’s case manager and other support team members as identified by the person within 45 days of providing services 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; and · 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. b. The license holder did not hold a discussion about how technology might be used to meet P1’s and P2’s desired outcomes as part of P1’s and P2’s initial planning meetings. The license holder was to document a summary of this discussion in the persons support plan. The summary must include: · a statement regarding any decision that is 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. Corrective Action Ordered: Within 60 days of receiving this order, you must: · meet with P1, P1’s legal representative, P1’s case manager and members of P1’s support team, and with P2, P2’s legal representative, P2’s case manager, and members of P2’s support team to determine the above mentioned information; and · maintain documentation of the above information in the person’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d). Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 13. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop service outcomes and supports as required. The license holder did not document for P1 and P2 the supports and methods to be implemented to support the person and 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: 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 that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will 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. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a service plan that includes the above-mentioned information for P1 and P2; and · maintain this service plan in P1’s and P2’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4, paragraphs (a) and (b). Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 14. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not summarize progress toward achieving identified outcomes as required. The license holder did not complete written reports for P1 and P2 at least once per year that included the following: · a summary of the person’s status and progress toward achieving the identified outcomes; · made recommendations; · identified the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete written reports for P1 and P2 that includes the information above; and · provide the reports to P1’s and P2’s legal representatives, case managers, and other members of P1’s and P2’s support teams. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g). 15. Violation: The license holder did not maintain an admission and discharge register as required. The license holder did not keep a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder. Corrective Action Ordered: Within 60 days of receiving this order, you must develop and admission and discharge register that includes the above mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 2. 16. Violation: For one person whose record was reviewed (P1), the license holder did not maintain service recipient records as required. a. The license holder did not maintain progress or daily log notes for P1. b. The license holder did not obtain a signed statement from P1’s legal representative authorizing the license holder to act in a medical emergency when P1’s legal representative cannot be reached or was delayed in arriving. Corrective Action Ordered: Within 60 days of receiving this order, you must: · begin maintaining progress notes in P1’s service recipient record; · obtain a signed statement from P1’s legal representative authorizing the license holder to act in a medical emergency; and · maintain this signed statement in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 17. Violation: For one person whose record was reviewed (P2), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder did not inform P2, and P2’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Corrective Action Ordered: Within 60 days of receiving this order, you must: · inform and provide copies of the above mentioned policies and procedures to P2, and P2’s case manager; and · obtain written acknowledgement from P2’s legal representative that P2 has been notified of your emergency use of manual restraints policy as required in Minnesota Rules, part 9544.0080. On an ongoing basis, you must maintain compliance as required in this subdivision.
Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on February 23, 2017, you were previously found in violation of this same statute. 18. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. The license holder did not incorporate positive support strategies in writing to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Within 60 days of receiving this order, you must: · document the positive support strategies for P1 and P2; · evaluate with P1 and P2, at least every six months, whether the identified positive support strategies currently meet the standards in subpart 2; and · determine whether changes are needed in the positive support strategies used based upon the results of the evaluation; and if so, make the changes. On an ongoing basis, you must maintain compliance as required in this subpart. Rule Violated: Minnesota Rules, part 9544.0030, subpart 1. Staffing Standards Violations 19. Violation: For two of four staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide an annual review of the program abuse prevention plan as required. 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 SP2 with an annual review of the license holder’s program abuse prevention plan in 2022 and 2023. b. The license holder did not provide SP3 with an annual review of the license holder’s program abuse prevention plan in 2022, 2023, and 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP3 with a review your program abuse prevention plan. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statues, section 245A.65, subdivision 3. 20. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation training as required. The license holder did not provide orientation to the following training topics to SP1 within 60 days of hire: · the job description and how to complete specific job functions; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061, and what constitutes the use of restraints, time out, seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, 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 with training on the topics above; and · maintain documentation of these trainings in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. 21. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training as required. a. The license holder did not provide SP2 with training on the following topics on an annual basis: · data privacy requirements according to Minnesota Statutes, section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act in 1996 (HIPPA), and staff responsibilities related to complying and data privacy practices. SP2 did not receive this training in 2022 and 2023; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. SP2 did not receive this training in 2022 and 2023; · sections 245A.65 and 626.557 governing maltreatment of vulnerable adults and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. SP2 did not receive this training in 2023; · the principles of person centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services provided by the staff person. SP2 did not receive this training in 2022 and 2023; · safe and correct use of manual restraints on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraints. SP2 did not receive this training in 2022 and 2023; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, and why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. SP2 did not receive this training in 2022 and 2023; · basic first aid. SP2 did not receive this training in 2022, 2023, and 2024; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. SP2 did not receive this training in 2022 and 2023. b. The license holder did not provide SP3 with training on the following topics on an annual basis: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices. SP3 did not receive this training in 2022, 2023 and 2024; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. SP3 did not receive this training in 2022 and 2023; · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. SP3 did not receive this training in 2023; · the principles of person centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provide by the staff person. SP3 did not receive this training in 2022 and 2023; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraints. SP3 did not receive this training in 2022 and 2023; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, and why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. SP3 did not receive this training in 2022 and 2023; · basic first aid. SP3 did not receive this training in 2022, 2023 and 2024; 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 SP2 with basic first aid training; · provide SP3 with training on basic first aid and data privacy; and · maintain documentation of these trainings in SP2’s and SP3’s personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. 22. Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP1 that included: · the date of the training; · the number of hours per subject area; and · the name of the instructor for all trainings provided to SP1. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 5. Policy and Procedures Violation 23. Violation: For one person whose record was reviewed (P3), the license holder did not enforce their policy and procedure for termination of services as required. The license holder issued a notice of service termination to P3 on April 22, 2019. The license holder did not enforce the program’s policy on service termination when the license holder did not notify the commissioner in writing of P3’s termination from a residential support service as defined in section 245D.03, subdivision 1, paragraph (c), clause (3). Statute Violated: Minnesota Statutes, section 245D.10, subdivisions 1 and 3a. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Nature, chronicity or severity of violations and effect of violation(s) on health, safety, or rights of persons served by the program The Commissioner considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a conditional license is appropriate. · Nature: The license holder was issued a Correction Order for its HCBS license on February 23, 2017, that cited nine violations, and a Correction Order on February 13, 2019, that cited one violation. Despite the corrective action that was ordered in the Correction Orders, the license holder continued to demonstrate noncompliance and did not provide program coordination, evaluation, and oversight of services at the time of the licensing review on January 6, 2025. · Chronicity: Your program received its adult foster care (AFC) license on July 8, 2015. Your program received its home and community-based services (HCBS) license on January 28, 2016. During the application process for both licenses you affirmed that you understood licensing rules and laws. DHS provided you direction and resources regarding these rules and laws, including the importance of compliance. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes the AFC licensing history: o November 20, 2025 Conditional License (this order) 1 violation o October 20, 2021 - Correction Order 1 violation The information below summarizes the HCBS licensing history: o November 20, 2025 Conditional License (this order) 22 violations (9 repeat) o February 13, 2019 – Correction Order 1 violation (complaint investigation) o February 23, 2017 – Correction Order 9 violations · Severity: The designated coordinator and designated manager did not provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your HCBS licensed program remains in compliance with licensing requirements. HCBS License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of your inability to hire a qualified and competent designated coordinator and designated manager, you were found in violation of the twenty-two HCBS licensing violations described in this order. You did not meet the responsibilities related to individual abuse prevention plans by not conducting accurate assessments of persons susceptibility to abuse and by not reviewing the existing plans annually with persons served and their support teams as required. These failures could negatively impact the health and safety of persons served, as staff do not have accurate information about persons susceptibility to abuse or specific measures to take to minimize the risk of abuse. Additionally, a person’s identified vulnerabilities can change over time and the without an annual review of the individual abuse prevention plan staff do not have current information about potential risks and the proactive strategies the staff would utilize to reduce these risks. You did not meet the responsibilities related to persons health needs. You did not document a description of the procedures for that you would follow in order to provide medication administration, monitor health conditions, and assist with or coordinate medical, dental, or other health related appointments. You did not document any risks or side effects of the medications, so they were readily available for staff review. Failing to ensure service recipients receive the necessary health services and medication could have resulted in significant health implications by those who are dependent on the competent assistance of the license holder. You did not complete assessments for persons served annually. Assessments are a core component to person centered service planning and delivery as they provide a picture of the person’s served strengths, functional skills and abilities and behavior or symptoms. This information is integral for identifying and implementing the appropriate level of supports and care that is unique to each person. Furthermore, you did not incorporate positive support strategies into the person’s individual plan. Positive supports are approaches that offer respectful and effective ways to help individuals increase quality of life and prevent or reduce behavioral risk. Without these strategies, the person’s behaviors related to their health and medical needs, as well as emotional well-being and personal growth could be negatively impacted. You did not prepare service outcomes and supports based on assessments of the person’s needs. Because the person’s level of need required intensive support services, you were required to do more than supervise him/her but to access his/her needs and to document supports and methods to support the person in acquiring, retaining, or improving skills. You did not have any documentation showing how you would address the person’s needs which included measurable and observable criteria for identifying when the desired outcome has been achieved. You did not show you provided any services beyond basic support services when you were legally required and paid to provide intensive support services. You did not provide orientation and annual training to direct support staff persons, including training on maltreatment reporting requirements. When direct support staff are not provided with orientation and annual training, staff may not be competent to provide services to persons and there is an increased risk of neglect or abuse to persons served by the program. Training staff is a critical part of ensuring persons served are kept safe and to ensure their rights are protected. The failure to provide staff training directly relates to health, safety, and well-being of persons served by the program. The nature and severity of the violations are such that continued operation would pose a significant threat to the health, safety, and rights of participants. Regarding chronicity, your failure to correct the violations demonstrates that sanctions short of revocation will not motivate you to remedy the violations. Therefore, the nature, severity and chronicity of the violations support the Order of Conditional License for your adult foster care license and your home and community-based services license. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of persons served in your program, available evaluations from consumers of your program, and information about the qualifications of staff persons working in your program. DHS has determined that it is appropriate to place your license on conditional status based on the violations identified below and the program evaluation. You have been licensed to provide family adult foster care since July 8, 2015. Additionally, you have been licensed to provide HCBS family residential services at your family AFC program since January 28, 2016. DHS is concerned about your program’s operation, well-being of persons served by your program, and your ability to demonstrate competent knowledge of applicable laws. DHS is concerned about your program’s operation because since you were first licensed to provided HCBS services in 2016, DHS has issued two correction orders, and twenty-two violations determined during the most recent licensing review. The number of HCBS violations demonstrates that you did not adequately oversee your responsibilities as a HCBS license holder to ensure compliance and take corrective action when ordered by the Commissioner. DHS’ concerns about your HCBS program’s operation and ability to demonstrate competent knowledge were also demonstrated in your inability to comply with service planning and health needs documentation requirements. These requirements protect the health and safety of persons served and are minimum standards for license holders. Inability to comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Service planning and health needs requirements are essential to keeping vulnerable adults safe and ensuring persons served are receiving necessary services. Your lack of service planning and documentation of health needs posed a risk that staff would not know about the unique needs of the vulnerable people served. From January 2025 to April 2025, Dakota County conducted a licensing investigation of your AFC license. As part of the investigation, Dakota County determined you did not provide primary care to the persons served in your home. The two residents in your home required one-to-one care and at times one resident required two-to-one care. To meet the residents’ needs you had to use outside caregivers to the point you did not provide primary care to the residents in your home. At times you split time between the adult foster home and another residence you own. You left one of the residents at the AFC home while you sometimes brought the other resident to the other residence with you. Because you are no longer the primary caregiver of the AFC home, your foster home does not meet the definition of a family adult foster care home under Minnesota Statutes, section 245A.02, subdivision 6f. In addition, this setting is not the environment initially chosen by the vulnerable adult. The vulnerable adult(s)/guardian(s) chose for the person to live in a family setting, with the specific license holder as the primary caregiver, as opposed to having multiple support staff. When the license holder is not the primary caregiver, they are violating the persons service-related rights under Minnesota Statutes, section 245D.04, subdivision 2, which states a person has a right to the services and supports identified in the support plan. Further, with additional staff, comes additional risk of harm. DHS has determined that an Order of Conditional License for your AFC license and your HCBS license is appropriate based on the violations identified above and the program evaluation. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services and your license to provide adult foster care services are on conditional licenses. Immediate corrective action required and ongoing monitoring You must immediately correct the violations cited above. Your Dakota County licensor will monitor your compliance with the terms of the conditional license and with all family adult foster care rules and laws. This will include unannounced visits by your Dakota County licensor. DHS licensors will monitor your compliance with the terms of the conditional license and with all home and community-based services rules and laws. This will include licensing reviews conducted by DHS licensors at your program. If you do not demonstrate substantial compliance with adult foster care requirements and home and community-based services requirements or with the terms of your conditional licenses that are provided below, DHS may take an additional licensing action, including revocation, against your license.
Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under your 245D license and your AFC license because the twenty-two HCBS violations (nine repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. Since the violations involved your lack of competence to hire and train competent Designated Coordinators and Designated Managers; they involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). Conditional License Terms In addition to complying with all licensing rules and statutes for family adult foster care and home and community-based services, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your licenses. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS Licensing for approval within 10 days of receiving this order. The notification must specify: · the length of time of the conditional status of your license; · the reasons your license was made conditional; and · include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the licenses are on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the licenses, the reasons the licenses were made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, other than SP4, who is responsible for delivery and evaluation of HCBS services provided by the license holder; · designate a managerial staff person, other than SP4, to provide program management and oversight of the HCBS services provided by the license holder; and · submit the names and qualifications for the person(s) who will fulfill the duties and responsibilities of your designated coordinator and designated manager to DHS HCBS Licensing for review and approval. It is your responsibility to ensure that these persons meet the necessary qualifications. · you must maintain documentation of your designated coordinator and designated manager’s qualifications in their personnel records and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 60 days of receiving this order, you must: · submit a written plan to DHS Licensing detailing how you will ensure the corrective action ordered in this order is completed. The written plan must detail the roles and responsibilities that your designated coordinator and designated manager will have in completing corrective action and auditing all persons served records; · complete an audit of all participant and personnel records according to your written plan; · submit the results of the audit to your DHS licensor. The results must include the name of the staff person that audited each person served and personnel record; and · based on results the audit and the corrective action ordered in the violations detailed above, you must bring all records into compliance. 4. During the duration of the conditional order, you must receive approval from your Dakota County licensor before admitting any new service recipients to the home. You must submit information about the prospective service recipient and their care needs, the funding source, and completed 6790 documents, when applicable, to the Dakota County licensor and receive written approval from the Dakota County licensor before admitting any new service recipient. Once you receive written approval from Dakota county, you must notify your DHS licensor that you are admitting a new service recipient. The notification to your DHS licensor must include the name of the person served, the name and contact information for the person’s case manager, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license.
5. You may not add additional services to your HCBS license for the duration of the conditional license. 6. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 7. You will not be granted any variances for your AFC or HCBS licenses for the duration of the conditional license. 8. You must submit a current staffing pattern to your Dakota County licensor quarterly by the first day of the month (January, April, July, and October). You must also submit a staffing pattern to your Dakota County licensor prior to any proposed staffing changes outside of minor adjustments not totaling more than a 2-hour change per week. You must submit timesheets to your Dakota County licensor within 48 hours upon request from your licensor. Submissions Submissions required as part of corrective action ordered must be sent to your DHS licensor at: 1. By secure email at kate.spenger@state.mn.us ; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Kate Spenger Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Submissions required as part of corrective action ordered must be sent to your Dakota County licensor at: 1. By secure email at deb.suek@co.dakota.mn.us ; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-554-6339 or mail using the information below: Dakota County Human Services ATTN: Deb Suek 1 Mendota Road West, Suite 300 West St. Paul, MN 55118 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all family adult foster care laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community Based-Services are required to follow Minnesota Statutes 245A, 245C and 245d, and Minnesota rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Tawnya Arueya, Supervisor, at 651-201-5571. Sincerely,
Jason Flint, Assistant Director Licensing Division Office of Inspector General cc: Deb Suek, Dakota County Community Services
|
