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December 23, 2025 Jeffery Feltz Community Living Options 26022 Main Street Zimmerman, Minnesota 55398-9346 License Number: 1070470 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Jeffery Feltz: On October 4, 2025, through October 7, 2025, a licensing review of Community Living Options, located at 43873 Forest Boulevard Harris, 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, paragraph (a). Violation: For three of twelve persons whose records were reviewed (P5, P7, and P10), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) within 24 hours of admission as required. a. The license holder did not provide P5 with an orientation to the PAPP for the community residential services (CRS) 1126587 when admission occurred on March 19, 2025. b. The license holder did not provide P7 with an orientation to the PAPP for the community residential services (CRS) 1070471 when admission occurred on September 11, 2025. c. The license holder did not provide P10 with an orientation to the PAPP for the community residential services (CRS) 1070501 when admission occurred on April 2, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P5 with an orientation to the PAPP and maintain documentation of this orientation in P5’s service recipient record; · provide P7 with an orientation to the PAPP, notify P7’s legal representative that the orientation was completed, and maintain documentation of this orientation in P7’s service recipient record; and · provide P10 with an orientation to the PAPP, notify P10’s legal representative that the orientation was completed, and maintain documentation of this orientation in P10’s service recipient record; On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For three persons whose records were reviewed (P1, P3, and P8), the license holder did not establish and enforce 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 develop an IAPP for P1 that included an individualized assessment of P1’s susceptibility of abuse and statements of the specific measures to be taken to minimize the risk of abuse. P1’s IAPP dated July 10, 2025, indicated that P1 was not susceptible to sexual abuse and self-abuse. This assessment was not consistent with information maintained elsewhere in P1’s record. b. The license holder did not review P3’s IAPP annually in 2024. The license holder reviewed P3’s IAPP on March 3, 2023, and May 10, 2024. c. The license holder reviewed P8’s IAPP with P8, P8’s legal representative, and P8’s case manager and other individuals identified by P8 or P8’s legal representative in annually in 2024 and 2025 but did not revise P8’s IAPP to reflect the results of this review. P8’s IAPP’s from 2023-2025 contained identical information, which is inconsistent with information found elsewhere in P8’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1’s IAPP to include an individualized assessment of the person’s susceptibility to abuse and statements of specific measures the program will take to minimize the risk of abuse to P1 and other vulnerable adults; · review and revise P8’s IAPP to include an individualized assessment of the person’s susceptibility to abuse and statements of specific measures the program will take to minimize the risk of abuse to P8 and other vulnerable adults; and · provide staff working with P1 and P8 with training on the updated IAPP’s; and · maintain documentation of this training in accordance with Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For four persons whose record were reviewed (P3, P4, P7 and P10), the license holder did not provide the person a written notice that identified the service recipient rights and an explanation of those rights as required. a. The license holder did not provide P3 with a written notice that identified the service recipient rights annually in 2024. The license holder provided P3 a written notice that identified their service recipient rights in March 2023 and May 2024. b. The license holder did not provide P4 with a written notice that identified the service recipient rights annually in 2023, 2024, and 2025. The license holder provided P4 a written notice that identified their service recipient rights in June 2023, July 2024, and August 2025. c. The license holder did not provide P7 and P10 with a written notice that included P7’s and P10’s protection-related rights that included the right to a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; and a setting that is free from hazards that threaten the person’s health or safety. At the time of the review, P7 and P10 lived in a residential site license according to chapter 245A, where the license holder was the owner, lessor, or tenant of the residential service site. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P7 and P10 with a copy of the service recipient rights identified above and maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivisions 3. Violation: For two persons whose records were reviewed (P4 and P10), the license holder did not provide service recipient protection-related rights as required. a. The license holder did not review the need for P4’s rights restriction based on the conditions for ending the restriction semiannually, at a minimum. The license holder reviewed P4’s rights restriction in July 2024 and February 2025. b. The license holder did not ensure the exercise and protection of P10’s right to have access to their personal possessions at any time. During a site visit on November 6, 2025, a DHS licensor observed a lock on P10’s bedroom closet door. Corrective Action Ordered: Immediately upon receiving this order, you must provide P10 with access to their personal possessions and ensure P10’s service recipient rights are exercised and protected. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not document health needs as required. a. The license holder did not maintain documentation in P3’s support plan addendum of the procedures the license holder would follow in order to use medical equipment, devices, or adaptive aides safely and correctly according to the written instructions of a licensed professional for P3’s power chair, prone stander, and hoyer lift. b. The license holder did not maintain documentation in P3’s support plan addendum of how the license holder would monitor health conditions according to written instructions from a licensed health professional, when assigned responsibility for P3’s range of motion exercises. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain the written instruction and documentation identified above and update P3’s support plan addendum to accurately reflect P3’s health service needs; · provide P3’s staff with training on P3’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For four persons whose record were reviewed (P6, P7, P9 and P10), the license holder did not complete medication administration record (MAR) reviews, as required. a. The license holder was assigned the responsibility for P6’s medication administration in P6’s support plan and support plan addendum. The license holder did not ensure P6’s MARs were reviewed to identify medication administration errors every three months at a minimum. b. The license holder was assigned the responsibility for P7’s medication administration in P7’s support plan and support plan addendum. The license holder completed MAR reviews for P7 that did not identify following medication errors: · The license holder documented no medication errors in the MAR review completed July 7, 2025, for April 2025 to June 2025; however, DHS identified medications that were not documented as administered. · The license holder documented no medication errors in the MAR review completed October 7, 2025, for July 2025 to September 2025; however, DHS identified medications that were not documented as administered. c. The license holder was assigned the responsibility for P9’s medication administration in P9’s support plan and support plan addendum. The license holder completed MAR reviews for P9 that did not identify following medication errors: · The license holder documented no medication errors in the MAR review completed January 10, 2025, for October 2024 to December 2024; however, DHS identified more than 20 doses of medication not documented as administered. · The license holder documented no medication errors in the MAR review completed July 21, 2025, for April 2025 to June 2025; however, DHS identified more than 10 doses of medication not documented as administered. d. The license holder did not report the following to P7’s, P9’s, and P10’s legal representative and case manager as they occurred when a dose of medication was not administered or treatment was not performed as prescribed, whether by error by the staff or the person or by refusal by the person. e. The license holder was assigned the responsibility for P10’s medication administration in P10’s support plan and support plan addendum. The license holder completed MAR reviews for P10 in October 2025, but did not accurately identify when a medication was not administered at least 10 times. Corrective Action Ordered: Within 30 days of receiving this order, you must: · begin completing MAR reviews for P6 a minimum of every three months and maintain documentation of these MAR reviews in P6’s service recipient record; · review P7’s MARs from April 2025 through current and P9’s MARs from October 2024 through current to identify any medication errors and based on the results of this review you must: o develop and implement a plan to correct patterns of medication administration errors when identified and o report any medication errors to P7’s and P9’s legal representative and case manager as required in this subdivision; · report the medication errors from the October 2025 MAR review to P10’s legal representative and case manager as required in this subdivision; · provide re-training to staff persons who are assigned responsibility of MAR reviews to ensure compliance with the requirements of 245D.05, subdivision 4; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 5. Violation: For one person whose record was reviewed (P8), the license holder did not meet requirements for administering injectable medications. The license holder did not maintain an accurate agreement specifying what injection may be given, when, how, and that the prescriber retained responsibility for the license holder's giving the injections. The license holder maintained an agreement from October 2025, in P8’s record that specified a registered nurse or licensed practical nurse will administer P8’s injectable medication. During a site visit, DHS licensors were told by the license holder that P8 self-administers their injectable medication. Corrective Action Ordered: Immediately upon receiving this order, you must: · obtain an accurate agreement signed by you, P8, and the prescriber that specifies the information detailed above; · you must maintain a copy of this agreement in P8’s service recipient record; · provide P8’s staff with training on the updates made to P8’s support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P10), the license holder did not maintain information on 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 the responsibility of medication administration for P10, including psychotropic medications. The license holder did not document a description of the target symptoms that each psychotropic medication was to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document a description of the target symptoms that each psychotropic medication is to alleviate for P10; · provide P10’s staff with training on the updates made to P10’s support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.06, subdivision 1. Violation: For one person whose record was reviewed (P11), the license holder did not complete incident reporting as required. The license holder did not notify P11’s case manager of the incident that occurred on June 3, 2023, within 24 hours. P11’s case manager was notified on June 5, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.061, subdivision 5 and 8. Violation: For one person whose record was reviewed (P9), the license holder did not report each single incident of emergency use of manual restraint (EUMR), as required. The license holder did not report each single incident of emergency use of manual restraint separately. The license holder documented on the form titled “Behavioral Intervention/Emergency Use of Manual Restraint and Internal Review” that more than one EUMR was performed with P9 on October 6, 2024; however, the license holder reported only one EUMR on the behavior intervention report form (BIRF) that the license holder submitted to the Department of Human Services and the office of the Ombudsman for Mental Health and Developmental Disabilities. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d). Violation: For two persons whose records were reviewed (P7 and P10), the license holder did not meet the requirements for initial service planning and delivery of intensive support services as required. The license holder did not determine the following information at P7’s and P10’s initial service planning meetings: · 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; and · 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 Required: Within 30 days of receiving this order, you must: · meet with P7 and P10, P7’s and P10’s legal representative and P7’s and P10’s case manager to determine the information identified above; · provide P7’s and P10’s staff with training on P7’s and P10’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose record were reviewed (P7 and P8), the license holder did not develop a service plan that documents the service outcomes and supports as required. The license holder did not develop a service plan that documented the methods and actions that will be used to support the P7 and P8 and to accomplish the service outcomes including information about any changes or modifications to the physical and social environments necessary when the service supports are provided. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document any changes or modifications to the physical and social environments necessary when the service supports are provided in P7’s and P8’s service outcomes and supports; · provide P7’s and P8’s staff with training on P7’s and P8’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.07, subdivision 3. Violation: For two persons whose records were reviewed (P2, P7), the license holder did not provide written reports as required. a. The license holder did not provide annual written reports to P2’s support team as assigned in P2’s support plan addendum. b. The license holder did not provide quarterly written reports to P7’s support team as assigned in P7’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a review that documents P2’s progress towards achieving identified outcomes in 2023 and 2024, and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in Minnesota Statutes, section 245D.071, subdivision 4 and provide report to P2’s support team as indicated in P2’s support plan addendum; · complete a review that documents P7’s progress towards achieving identified outcomes in 2023, 2024, and 2025, and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in Minnesota Statutes, section 245D.071, subdivision 4 and provide report to P7’s support team as indicated in P7’s support plan addendum; · provide P2’s and P7’s staff with training on P2’s and P7’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P4), the license holder did not provide service outcomes and supports as required. The license holder did not develop a service plan that documented the service outcomes and supports based on the assessments competed under subdivision 3 and the requirements in section 245D.07, subdivision 1a. Corrective Action Ordered: Within 30 days of receiving this order you must: · use the information of P4’s identified needs, interests, preference, and desired outcomes as specified in the support plan and support plan addendum, and in compliance with the requirements of this subdivision; to identify outcomes P4 desires; · develop a service plan that documents the service outcomes and supports according to this subdivision; · provide P4’s staff with training on P4’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P4), the license holder did not complete service plan review and evaluation as required. The license holder did not maintain a summary of the discussion on how technology might be used to meet P4’s desired outcomes in 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For four persons whose records were reviewed (P1-P3, and P8), the license holder did not incorporate and evaluate positive support strategies as required. a. The license holder did not incorporate positive support strategies in writing to P1’s and P3’s existing treatment, service, or other individual plan required of the license holder. b. The license holder did not evaluate with P2 and P8 whether the identified positive support strategies current met the standards in subpart 2, at least every 6 months. P2’s and P8’s positive support strategies were evaluated in October 2024 and October 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · incorporate positive support strategies for P1 and P3 in their treatment, service, or other individual plans; · provide P1’s and P3’s staff with training on the updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For thirteen of twenty-five staff persons whose record were reviewed (SP4, SP6, SP7, SP9 – SP11, SP13 – SP15, SP18, SP20, SP22 and SP23), the license holder did not provide orientation training as required. a. The license holder did not provide basic first to SP6, SP9 and SP10 within 60 days of hire. · The license holder documented SP6’s date of hire as June 17, 2024. The license holder provided basic first aid to SP6 on April 4, 2025. · The license holder documented SP9’s date of hire as July 21, 2025. The license holder provided basic first aid to SP9 on October 1, 2025. · The license holder documented SP10’s hire date as March 2, 2025. The license holder provided basic first aid to SP10 on May 14, 2025. b. The license holder did not provide the following trainings to SP4, SP9 – SP11, SP13 – SP15, SP18, SP20, and SP22 – SP23: · the license holder’s current policies and procedures under Minnesota Statutes, chapter 245D, including their location and access and staff responsibilities related to implementation of the police and procedures on health service coordination and care; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. The license holder did not provide SP4, SP11, SP13, SP18 and SP23 with training on the license holder’s current policy and procedures, including their location and access and staff responsibilities related to implementation of the following policies and procedures: · service grievance and complaint procedures; · service suspension and termination; and · service admission. d. The license holder did not provide SP6 with training on the license holder’s current policy and procedures, including their location and access and staff responsibilities related to implementation of the following policies and procedures: · service grievance and complaint procedures; · service suspension and termination; · service admission; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.
e. The license holder did not provide SP22 with training on the license holder’s current policy and procedures, including their location and access and staff responsibilities related to implementation of the following policies and procedures: · service suspension and termination; and · service admission. f. The license holder did not provide SP7 with training on the license holder’s current policy and procedures, including their location and access and staff responsibilities related to implementation of the policies and procedures: · strategies to minimize the risk of sexual violence, including concept of health relationships, consent, and bodily autonomy of people with disabilities; and · service suspension and termination. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP4, SP6, SP7, SP9 – SP11, SP13 – SP15, SP18, and SP22 – SP23 with the trainings listed in (b - f) and maintain documentation according to Minnesota statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For eight staff persons whose records were reviewed (SP1-SP3, SP5, SP8, SP12, SP17, and SP24), the license holder did not provide annual training as required. a. The license holder did not provide training to SP1, SP2, SP5, SP8, SP12, SP17, and SP24 on strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities annually in 2023, 2024, and 2025. b. The license holder did not provide SP3 training on strategies to minimize the risk of sexual violence, including concepts of health relationships, consent, and bodily autonomy of people with disabilities annually in 2024 and 2025. c. The license holder did not provide SP3 training on 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, or why such procedures are not safe in 2025. The license holder last provided SP3 with this training in March 2024. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP1-SP3, SP8, SP12, SP17, and SP24 with the annual trainings listed above and maintain documentation according to Minnesota statutes 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For ten staff persons whose records were reviewed (SP3, SP5, SP7 - SP11, P15, P18, and P20), the license holder did not maintain staff training records as required. · The license holder did not document the date of the training, the number of hours per subject area, and the name of the instructor for SP8’s - SP11’s, SP15’s, SP18’s, and SP20’s trainings. · The license holder did not document the date of the training and the name of the instructor for all SP3’s, SP5’s and SP7’s trainings. Corrective Action Ordered: On an ongoing basis you must maintain compliance as required in this subdivision. 20. Citation: Minnesota Statutes, section 245D.095, subdivision 1. Violation: The license holder did not maintain record-keeping systems as required. The license holder did not ensure that the content and format of personnel records were uniform and legible according to the requirements of this chapter. DHS reviewed twenty five personnel records which contained inconsistencies in the location of the information required in Minnesota Statutes 245D.09 and 245D.095 resulting in inabilities and difficulties verifying compliance within this chapter. Corrective Action Ordered: Within 30 days of receiving this order you must develop and implement a uniform and legible format of maintaining personnel records. 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. Coty Aust, HCBS Licensor Licensing Division Office of Inspector General 651-431-4605
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