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November 25, 2025 Marcell Garretson, Authorized Agent Fidelity Healthcare LLC 8525 Edinbrook Crossing, Suite 111 Brooklyn Park, Minnesota 55443 License Number: 1103127(245D – Home and Community-Based Services) CORRECTION ORDER Dear Marcell Garretson: On September 10, 2025, a licensing review of Fidelity Healthcare LLC, located at 8525 Edinbrook Crossing, Suite 111, Brooklyn Park, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one of five persons whose records were reviewed (P3), the license holder did not provide orientation to vulnerable adult maltreatment reporting procedures as required. The license holder did not provide P3 with orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder initiated P3’s services on April 1, 2024, and provided this orientation on July 1, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for abuse prevention plans as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder did not review P1’s individual abuse prevention plan (IAPP) with P1 and P1’s interdisciplinary team annually in 2022, 2023, and 2024. The license holder reviewed P1’s IAPP on August 28, 2025. b. The license holder did not provide P3 with orientation to the program abuse prevention plan within 24 hours of admission. The license holder initiated P3’s services on April 1, 2024, and provided P3 with this orientation on August 15, 2025. c. The license holder provided multiple services to P2. The license holder failed to develop an IAPP for P2 that included a statement of measures that would be taken to minimize the risk of abuse to P2 within the scope of each licensed service P2 was receiving. d. The license holder did not develop an individual abuse prevention plan for P3 prior to or upon service initiation. The license holder initiated P3’s services on April 1, 2024, and developed an IAPP for P3 on August 15, 2025. The IAPP that the license holder developed did not include an individualized assessment of P3’s susceptibility of abuse. P3’s IAPP documented that P3 is not susceptible to any areas of abuse. That information is not consistent with information reviewed elsewhere in P3’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct an individualized assessment of P2 and P3’s susceptibility to abuse; · based on the assessment you must revise P3’s IAPP to include the areas where P3 is susceptible to abuse and document the measures that will be taken to minimize the risk of abuse; · revise P2’s IAPP, based on the assessment, to include the areas where P2 is susceptible to abuse and document the measures that will be taken to minimize the risk of abuse for each service P2 is receiving; · review P2 and P3’s IAPP with P2, P3 and P2’s and P3’s case managers and other members of the support team. You must maintain documentation with the date this was reviewed; and · provide training to all direct support staff that provide direct support services to P2 and P3 on P2’s and P3's individual abuse prevention plans, so they are able achieve and demonstrate an understanding of the person as a unique individual, and how to implement the IAPP. On an ongoing basis, you must maintain compliance as required in this subdivision 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not provide service recipient rights as required. a. The license holder did not provide P1 and P2 with a written notice that identified the service recipient rights, and explanation of those rights within five working days of service initiation and annually thereafter for all services P1 and P2 received from the license holder. b. The license holder did not provide P3 with a written notice that identified the service recipient rights, and an explanation of those rights within five working days of service initiation and annually thereafter. The license holder initiated P3’s services on April 1, 2024, and provided the rights to P3 on July 1, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P2 and P3 with a written notice that identifies the service recipient rights, and an explanation of those rights. You must maintain documentation of P1’s, P2’s, and P3’s receipt of a copy and explanation of the rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.06, subdivision 1 and Minnesota Statutes, section 245D.11, subdivision 2. Violation: For one person whose record was reviewed (P3), the license holder did not complete responsibilities related to incident response and reporting. The license holder did not maintain information about and report an incident to P3’s case manager within 24 hours of an incident that occurred on July 29, 2025, while services were provided. Additionally, the license holder did not follow requirements in section 245D.11 when they did not maintain an incident report that included: · the name of the person or persons involved in the incident; · the date, time, and location of the incident or emergency; · a description of the incident or emergency; · a description of the response to the incident or emergency and whether a person's support plan addendum or program policies and procedures were implemented as applicable; · the name of the staff person or persons who responded to the incident or emergency; and · the determination of whether corrective action is necessary based on the results of the review. Corrective Action Ordered: Within 30 days of receiving this order, you must; · maintain an incident report for the incident that occurred on July 29, 2025, that includes the above documented information; and · report the incident to P3’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1 and Minnesota Statues, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P3), the license holder did not provide services in response to the person’s identified needs and in compliance with the federal waiver plans as required. a. The license holder did not provide services as assigned in P3’s support plan. The prevision of services did not comply with the requirements of this chapter and the federal waiver plans. The license holder maintained information in P3’s record that documented P3 was to receive four hours of in person support and one hour of remote support per day. · the license holder maintained information in P3’s record that documented multiple dates that remote support occurred; however, the daily log notes indicated the license holder left a voicemail for P3, which is not live, two way communication; and · the majority of the log notes maintained in P3’s record documented that direct support staff “checked in” on P3, however, the license holder did not provide the four hours of in person support as assigned in P3’s support plan. b. The license holder did not provide services in response to P3’s identified needs as specified in P3’s support plan, and in compliance with the requirements of this chapter. The license holder was assigned to provide integrated community supports to P3, including training/habilitation and support to meet P3’s individualized assessed needs and goals in household management, community resources and adaptive skills. Multiple daily log notes maintained in P3’s record documented that the direct support staff called to “check in”, however, no support was provided beyond that in any of the community living service categories where P3 was assessed to have needs and goals. Corrective Action Ordered: Within 30 days or receiving this order, you must meet with P3, P3’s case manager, and other members of the support team to evaluate the in person and remote hours needed to support P3 in the community living service categories. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, sections 245D.07, subdivision 2 and 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet service planning requirements for basic support services or intensive support services. a. The license holder did not complete a preliminary support plan addendum for P2 within 15 calendar days of service initiation for two services the license holder was providing P2. b. The license holder did not complete a preliminary support plan addendum for P1 and P3 based on the support plan within 15 calendar days of service initiation. c. The license holder did not conduct assessments for P1 and P3 in the following areas before providing 45 days of service: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. d. The license holder did not hold an initial service planning meeting with P1 and P1’s case manager, or P3 and P3’s case manager, and other members of the support team to determine the following information: · the scope of the services to be provided to support the person's daily needs and activities; · the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; · the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and · a discussion of how technology might be used to meet the person's desired outcomes, including a summary of this discussion, 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 30 days of receiving this order, you must: · complete a preliminary support plan addendum for P2 based on the support plan for both basic services the license holder is providing P2; · conduct assessments in the above documented areas. The assessments must provide information about P1 and P3 that describes P1’s and P3’s overall strengths, functional skills and abilities, and behaviors or symptoms; · review P1’s and P3’s assessments with P1 and P3, P1’s and P3’s case manager and other members of the support team. You must maintain documentation with the date this was reviewed; · provide training on P1’s and P3's assessments to all direct support staff that provide direct support services to P1 and P3; and · hold a meeting with P1 and P3, P1’s and P3’s case manager and other members of the support team to determine the information documented above. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not develop a service plan that documented service outcomes and supports as required. The license holder did not develop a service plan for P1 or P3 that documented the service outcomes and supports that included the following 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: · methods or actions that would be used to support the person and to accomplish the service outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcomes had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan for P1 and P3 that documents the service outcomes and supports that includes the above documented supports and methods; · submit to and obtain dated signatures from P1 and P3 and P1’s and P3’s case manager to document completion and approval of the assessment and support plan addendum, including the service outcomes and supports; and · provide training to all direct support staff that provide direct support services to P1 and P3 on P1’s and P3’s service outcomes and supports. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not conduct service plan review and evaluation as required. The license holder did not complete service plan and review meetings with P1, P1’s case manager and other people identified by P1 or with P3, P3’s case manager and other people identified by P3 to determine whether changes are needed to the service plan based on the assessment information, the license holder's evaluation of progress toward accomplishing outcomes, or other information provided by the support team or expanded support team. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P1, P3, P1’s case manager, P3’s case manager and other members of the support teams to participate in the ongoing review and development of the service plan to determine whether changes were needed to the support plan addendum. The annual review must include the following: · a discussion of how technology might be used to meet the person's desired outcomes, including a summary of this discussion, 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; and · options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider, including a summary of the discussion, a statement about any decision made regarding transitioning out of a provider-controlled setting and a description of any further research or education that must be completed before a decision regarding transitioning out of a provider-controlled setting can be made. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.95, subdivision 2. Violation: For one person whose record was reviewed (P3), the license holder did not maintain an admission and discharge record as required. The license holder did not maintain 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 30 days of receiving this order, you must maintain an admission and discharge record. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, Minnesota Statutes, section 245D.10, subdivision 3a. Violation: For one person whose record was reviewed (P4), the license holder did not enforce policies and procedures for service termination as required. The license holder issued P4 a notice of service termination on September 30, 2025. The license holder did not make a request to P4’s case manager for intervention services, or other professional consultation or intervention services to support the person in the program prior to giving P4 the notice of service termination. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder did not inform P2 and P3 and P1’s, P2’s, and P3’s case manager of the policies and procedures affecting P1’s, P2’s, and P3’s rights, and provide copies of the following policies and procedures, within 5 working days of service initiation. • grievance policy; • temporary service suspension policy; • service termination policy; • emergency use of manual restraints policy; and • data privacy policy. The license holder initiated P3’s services on April 1, 2024, and provided these policies and procedures to P3 and P3’s case manager on July 1, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1’s and P2’s case manager with the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate the identified positive support strategies with P1, P2 and P3 every 6 months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate P1’s, P2’s and P3’s identified positive support strategies. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, Minnesota Statutes, section 245A.65, subdivision 3 Violation: For three of six staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation to maltreatment reporting as required. c. The license holder did not provide SP1, SP2, and SP3 with orientation on vulnerable adult maltreatment reporting including a review of all the license holder’s internal policies and procedures related to prevention and reporting of maltreatment of individuals receiving services. The license holder provided SP1 with this orientation on August 27, 2021. d. The license holder did not provide SP3 with orientation to the license holder’s program abuse prevention plan within 72 hours of SP3 first providing direct contact services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP2 and SP3 with the orientation to maltreatment reporting documented above; · maintain documentation in SP2 and SP3’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation to maltreatment reporting was provided; · for the direct support staff that did not have orientation training requirements met, you must provide the orientation; and · maintain documentation with your audit findings. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation training as required. The license holder did not provide the following orientation to SP1, SP2, and SP3 within 60 calendar days of hire: · the job description and how to complete specific job functions, including responding to and reporting incidents, and following safety practices established by the license holder and as required; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures; · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1, SP2, and SP3 with the orientation trainings documented above; · maintain documentation in SP1’s, SP2’s, and SP3’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation training was provided; · for the direct support staff that did not have orientation training requirements met, you must provide the orientation; and · maintain documentation with your audit findings. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide SP1, SP2, and SP3 with orientation to individual needs before having unsupervised direct contact with a person served, including the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1, SP2, and SP3 with orientation to individual service recipient needs documented above for any person they provide direct contact to; · maintain documentation in SP1’s, SP2’s, and SP3’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation to individual service recipient needs was provided; · for the direct support staff that did not have orientation to individual service recipient needs, you must provide the orientation; and · maintain documentation with your audit findings. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.081, subdivisions 1 and 2. Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight. a. The license holder failed to ensure that the staff person the license holder identified as the designated coordinator met the following responsibilities: · coordination of service delivery and evaluation for each person served by the program as identified in subdivision 2; and · program management and oversight that includes evaluation of the program quality and program improvement for services provided by the license holder as identified in subdivision 3. b. The license holder failed to ensure that the staff person the license holder identified as the designated coordinator provided supervision, support, and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan 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 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 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. The failure to provide program coordination and oversight of the services is evidenced in citations 1 through 15.
Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not ensure that the designated managerial staff person provided program management and oversight of the services provided as required. The license holder failed to ensure the staff person the license holder identified as the designated manager met the following responsibilities: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress toward accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the services is evidenced in citations 1 through 16.
Corrective Action Ordered: 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. 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 64953 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. Kathleen “Katie” Crowley HCBS Licensor Licensing Division Office of Inspector General 651-431-2631
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