Minnesota

December 15, 2025

William Thompson, Authorized Agent

Faces North

3917 Winnetka Avenue North

New Hope, Minnesota 55427

License Number: 1072441 (245D – HCBS)

CORRECTION ORDER

Dear William Thompson:

On October 22, 2025, a licensing review of Faces North, located at 3917 Winnetka Avenue North, New Hope, 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 2.

Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not establish individual abuse prevention plans (IAPP) as required.

Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year.

a. The license holder did not review P1’s IAPP annually in 2025. The license holder most recently reviewed P1’s IAPP in July, 2024. Additionally, the license holder assessed P1 as not being susceptible to self-abuse in P1’s IAPP. This contradicted information found elsewhere in P1’s support plan addendum.

b. The license holder did not develop an IAPP for P2 that included a statement of measures that would be taken to minimize the risk of sexual abuse, self abuse and financial exploitation to P2. Additionally, the license holder did not review P2’s IAPP annually in 2024 and 2025. The license holder most recently reviewed P2’s IAPP in July, 2023.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· revise P1’s IAPP to accurately assess P1’s susceptibility to abuse;

· revise P2’s IAPP to include measures and specific action the program will take to minimize the risk of abuse within the scope of licensed services;

· review the updated IAPP with P1 and P2 and their support team and maintain documentation of this review in P1’s and P2’s service recipient record; and

· provide training to the revision of P1’s and P2’s IAPP to all staff that provide services to P1 and P2 and maintain documentation of this training according to Minnesota Statutes, section 245D.095.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide service recipient rights as required.

a. The license holder did not provide P1 a written notice that identified the service recipient rights annually. The license holder most recently provided P1 a written notice that identified the service recipient rights in August, 2020. Additionally, the license holder did not provide P1 a written notice that identified the following service recipient rights:

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· have freedom and support to access food and potable water at any time;

· have the freedom to furnish and decorate the person's bedroom or living unit;

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects;

· a setting that is free from hazards that threaten the person's health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

b. The license holder did not provide P2 with a written notice that identified the service recipient rights and explanation of those rights annually 2024 and 2025. The license holder most recently provided P2 a written notice that identified the service recipient rights in April, 2023.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· provide P1 and P2 with a written notice that identifies the service recipient rights in subdivisions 2 and 3, and an explanation of those rights; and

· maintain documentation of P1’s and P2’s receipt of a copy and an explanation of the rights.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required.

3. Citation: Minnesota Statutes, section 245D.05, subdivision 1.

Violation: For one person whose record was reviewed (P2), the license holder did not maintain documentation of how the person’s health needs would be met as required.

The license holder was assigned the responsibility of meeting P2’s health service needs according to P2’s support plan addendum. The license holder did not maintain documentation on how P2’s health needs would be met, including a description of the procedure the license holder would follow in order to use medical device, including such as glucometer, safely and correctly according to written instructions from a licensed health professional for P2.

Corrective Action Ordered: Within 30 days of receiving this order, you must document how P2’s health needs would be met, including a description of procedures detailed above. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.05, subdivision 2.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not implement medication administration as required.

The license holder was assigned responsibility for medication administration for P1 and P2. The license holder did not document on P1’s and P2’s medication administration record (MAR) the information on the current prescription label or the prescriber's current order that included the description of the medication or treatment to be provided, and the frequency.

Corrective Action Ordered: Within 30 days of receiving this order, you must ensure that the information detailed above is documented in P1’s and P2’s MAR. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not review medication administration records (MAR) as required.

The license holder was assigned responsibility for medication administration for P1 and P2. The license holder did not review P1’s MAR to identify medication administration errors at a minimum every three months in 2023 and 2024. The license holder did not review P2’s MAR to identify medication administration errors at a minimum every three months in 2023, 2024 and 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s MARs from January 2025 to current to identify medication administration errors and document the review in P2’s support plan addendum. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required.

"Target symptom" refers 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 of medication administration for P1 and P2, including psychotropic medications. The license holder did not to document a description of the target symptoms that each psychotropic medication was to alleviate for P1 and P2.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P1’s and P2’s support plan addendum that includes a description of the target symptoms that each psychotropic medication is to alleviate. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For one person whose record was reviewed (P1), the license holder did not provide person-centered planning and service delivery as required.

The license holder did not provide services in response to the P1's identified needs as specified in the support plan and the support plan addendum dated July 11, 2024. P1’s support plan addendum indicated that P1 required the presence of staff at the service site while services are being provided. On December 21, 2024, P1 was unsupervised during the overnight hours.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision

8. Citation: Minnesota Statutes, section 245D.071, subdivision 3 and 5.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete assessments and service planning review for intensive services as required.

a. The license holder did not review P1’s and P2’s assessments annually with P1’s and P2’s support team in 2023, 2024, or 2025.

b. The license holder did not discuss the following topics with P1 and P2 and members of P1’s and P2’s expanded support team in 2023 or 2024:

· how technology might be used to meet P1’s desired outcomes at least once per year; and

· options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider.

c. The license holder did not provide an opportunity for the case manager to participate in service plan review for P1 at least once per year in 2023 or 2024.

d. The license holder did not provide an opportunity for the case manager to participate in service plan review for P2 at least once per year in 2023, 2024 or 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· review P1’s and P2’s assessments;

· maintain documentation of the assessment in P1’s and P2’s record; and

· meet and discuss with P1 and P2 and their support team how technology might be used to meet P1’s and P2’s desired outcomes and document a summary of this discussion that includes:

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 order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.071, subdivision 4.

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 develop a service plan that documented the following supports and methods to be implemented to support P1 and P2 to accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being:

· the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about;

o any changes or modifications to the physical and social environments necessary when the service supports are provided;

o any equipment and materials required; and

o techniques that are consistent with the person’s communication mode and learning style;

· the measurable and observable criteria for identifying when the desired outcomes had been achieved and how the 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 supports and methods for P1’s and P2’s desired outcomes including the information detailed above;

· submit to and obtain dated signatures from P1, P1’s case manager, P2 and P2’s case manager for approval;

· provide orientation to P1’s and P2’s documented supports and methods to all staff who provide direct support services to P1 and P2; and

· implement the supports and methods for P1’s and P2’s desired outcomes and track data related to their outcomes.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Rules, 9544.0030 subpart 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate the identified positive support strategies with P1 and P2 at least every six months in 2023, 2024, and 2025.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· evaluate the identified positive support strategies with P1 and P2 and document the evaluation in P1’s and P2’s support plan addendums; and

· 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.

Additionally, you must evaluate the identified positive support strategies with P1 and P2 at least every six months. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subpart.

11. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required.

The license holder did not provide SP1 and SP2 with an orientation to the PAPP within 72 hours of first providing direct contact.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· provide orientation to SP1 and SP2 on the PAPP; and

· maintain documentation of the orientation in SP1’s and SP2’s personnel file according to Minnesota Statutes, section 245D.095.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required.

a. The license holder did not provide the following orientation training to SP1 within 60 days of hire:

· 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 Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied 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; 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 the following orientation training to SP2 within 60 days of hire:

· 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;

· 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: The corrective action for this citation is listed in citation 14. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required.

a. The license holder did not provide SP1 and SP2 with medication administration training, from a training curriculum developed by a registered nurse or appropriate licensed health professional, that included an observed medication administration skill assessment by the trainer.

b. The license holder did not provide SP1 and SP2 with an orientation to service recipient needs that included review and instruction on the person’s support plan or support plan addendum, and individual abuse prevention plan, as it related to the responsibilities assigned to the license holder, 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 and SP2 to the orientation requirements identified above; and

· maintain documentation of the orientation requirements provided to SP1 and SP2 in their personnel file according to Minnesota Statutes, section 245D.095.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

14. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual training as required.

a. The license holder did not provide SP1 with the following annual training in 2024 or 2025:

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04;

· sections 245A.65 and 626.557 governing maltreatment reporting and service planning for 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;

· 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 SP1 with annual training to 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 in 2024.

c. The license holder did not provide SP2 with the following annual training in 2024 and 2025:

· 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;

· 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 and SP2 with the above-mentioned trainings; and

· maintain documentation of the completed trainings in SP1’s and SP2’s personnel file according to Minnesota Statutes, section 245D.095.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

15. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required.

The license holder did not maintain a personnel record for SP1 and SP2 that documented SP1’s and SP2’s training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor.

Corrective Action Ordered: Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Violation: The license holder did not ensure the designated coordinator and the designated manager 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 (SP3), provided supervision, support, and evaluation of activities that include:

• 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 (SP3) 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 1 through 16 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 submit the following to your licensor:

· the name of the person or persons, other than SP3, that you have identified to perform the duties of the designated coordinator and the designated manager; and

· the qualifications of your designated coordinator and designated manager according to Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

You must verify and document their competence according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3. On an ongoing basis, you must maintain compliance as required in these subdivisions.

17. Citation: Minnesota Statutes, section 245C.04, subdivision 7.

Violation: The license holder was aware SP4 had a legal name change in November 2024. The license holder did not initiate a new background study or notify the commissioner of the name change for SP4. The license holder initiated a new background study for SP4 study on October 28, 2025.

Corrective Action Ordered: Immediately, you must comply with the background study requirements in Minnesota Statutes, chapter 245C.

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 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.

Tammi Mitei, HCBS Human Services Licensor

Licensing Division

Office of Inspector General

651-431-6341

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/