|
January 28, 2026 Oladipo Ajayi, Authorized Agent Dominion Cares 1225 Southwest 304th Street Federal Way, Washington 98023 License Number: 1087221 (245D – HCBS) CORRECTION ORDER Dear Oladipo Ajayi: On January 7, 2026, a licensing review of Dominio, located at 555 3rd Avenue Northwest, Suite B, Hutchinson, 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 three persons whose record was reviewed (P2), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment as required. The license holder did not provide P2 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours of admission on April 19, 2023. The license holder provided this to P2 in February 2025. 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 develop and review the individual abuse prevention plan (IAPP) as required. 245A.02, subdivision 2b defines annual or annually as prior to or within the same month of the subsequent calendar year. a. The license holder developed an IAPP for P1 and P2 that identified areas where they were susceptible to abuse or at risk of abusing other vulnerable adults. The license holder did not include statements of measures, including specific actions, that the program would take to minimize the risk of abuse to that person within the scope of the license services, when the individual assessment required in section 626.557, subdivision 14, paragraph (b), indicated the need for measures. b. The license holder developed an IAPP for P3, that identified they were not susceptible to abuse; however, this information was inconsistent with other information maintained in their record. The license holder did not develop an IAPP for P3 that included the following: · an assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults and the person’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults; and · measures with specific actions the program would take to minimize the risk of abuse within the scope of the licensed services. c. The license holder did not review P1 and P3’s IAPP annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · establish and enforce IAPPs for P1-P3 that meet the requirements of this section; · review P1-P3’s IAPPs with the person, their legal representative, if applicable, and their case manager; and · maintain documentation of this review in P1-P3’s record. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not provide the service recipient rights as required. a. The license holder did not provide P1’s legal representative with a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights annually in 2025. b. The license holder did not provide P1’s legal representative with a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights annually in 2023 and 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1’s legal representative and P3 a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights; and · maintain documentation of the audit results at your program for review by DHS licensors. 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 1, paragraph (b). Violation: For one person whose records was reviewed (P1), the license holder did not document how health needs would be met as required. The license holder was assigned responsibility for meeting P1’s health needs in the support plan including the use of a wheelchair and food puree. The license holder did not maintain documentation on how the person’s health needs would be met, including a description of the use of medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P1’s service recipient record that includes a description of the procedures you will follow in order to meet the person’s health needs identified above. 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.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide service in compliance with the requirements of this chapter and the federal waiver plan as required.
The license holder did not comply with the federal waiver plan when the license holder provided individualized home supports with family training to P1. P1 and their delegated staff member are sisters. According to the Community-Based Services Manual, the individualized home supports with family training and their delegated staff members may not be relatives and paid to provide this service.
Corrective Action Ordered: Within 30 days of receiving this order, you must comply with the federal waiver plan as outlined in the Community-Based Services Manual. 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.071, subdivision 3 and 5. Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments and initial service planning as required. a. The license holder did not complete the following assessments for P1 that produced information that described P1’s overall strengths, functional skills and abilities within 45 days of service initiation: · P1'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; · P1'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 · P1'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. b. The license holder did not conduct an annual assessment for P1 in 2025. c. The license holder did not participate in an annual meeting with P1 and their support team in 2025. Corrective Action Ordered: Corrective Action Ordered: Within 30 days of receiving this order, you must: · revise P1’s assessments to produce information about P1’s overall strengths, functional skills, and abilities; and · review P1’s assessments with P1, P1’s legal representative, and P1’s case manager; · maintain documentation in P1’s record that includes the date the assessments were reviewed; and · meet with P1 and their support team to discuss ongoing review and development of the service plan. 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.095, subdivision 3. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not maintain service recipient records as required. a. The license holder did not provide annual written reports to P1 and P2, P1’s legal guardian, and P1 and P2’s case manager regarding P1 and P2’s progress or status that was assigned in P1 and P2’s support plan addendum. b. The license holder did not maintain progress or daily log notes that are recorded by the program in P3’s service recipient records.
Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 and P2, and their support team, a written report regarding the person’s progress or status. Compliance will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2) the license holder did not inform and provide policies and procedures to the case manager as required. The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P2 and P2’s case manager within five working days of service initiation April 19, 2023: · grievance policy and procedure; · service suspension policy and procedure; · termination policy and procedure; and · emergency use of manual restraints policy and procedure. The license holder provided the above-mentioned policies to P2 and P2’s case manager in February 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. 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 with P1-P3 whether the identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months. Corrective Action Ordered: Withing 30 days of receiving this order, evaluate with P1-P3 positive support strategies and maintain documentation in their service records. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For four of four staff persons whose records were reviewed (SP1-SP4), the license holder did not provide orientation training as required. The license holder did not provide and ensure completion of orientation sufficient to create staff competency for SP1 through SP4 that combined supervised on-the-job training with review of and instruction on the required topic areas within 60 days of hire: a. SP1 was hired on January 28, 2025. The license holder did not provide orientation on the following required topic areas: · responding to and reporting incidents as required under section 245D.06, subdivision 1; · following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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; · 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 (provided to SP1 in July 2025); and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. b. SP2 was hired on July 29, 2024. The license holder did not provide orientation on the following required topic areas: · responding to and reporting incidents as required under section 245D.06, subdivision 1; · following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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; · 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 (provided to SP2 in December 2024); and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. SP3 was hired on December 27, 2023. The license holder did not provide orientation on the following required topic areas: · responding to and reporting incidents as required under section 245D.06, subdivision 1; · following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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; · 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. d. SP4 was hired on March 19, 2024. The license holder did not provide orientation on the following required topic areas: · responding to and reporting incidents as required under section 245D.06, subdivision 1; · following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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; · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure that SP1-SP4 receives review and instruction on all the above required training topics. This must be documented in the staff person’s personnel record and must include the topic, date, instructor, and hours of training per subject area. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For four staff persons whose records were reviewed (SP1-SP4) the license holder did not provide orientation to individual service recipient needs as required. The license holder did not maintain documentation sufficient to determine that SP1 through SP4, before having unsupervised direct contact with a person served by the program or for whom the staff person has not previously provided direct support, reviewed and received instruction on the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, including 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 through SP4 with orientation to the individual service recipient needs for each person to whom the staff person provides direct support; and · maintain documentation that this orientation was provided in the staff person’s personnel file. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance by ensuring that orientation to individual service recipient needs is provided to all staff persons before the staff person provides unsupervised direct contact and any time the plans are revised, as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three staff persons whose records were reviewed (SP2-SP4), the license holder did not provide annual training as required. 245A.02, subdivision 2b defines annual or annually as prior to or within the same month of the subsequent calendar year. The license holder did not provide SP2-SP4 training on the required topic areas annually: a. The license holder did not provide SP2 with training on the following required topic areas annually in 2025: · 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 SP3 with training on the following required topic areas annually in 2024 and 2025: · 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; 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 with training on the following required topic areas annually in 2025: · 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 (HIPAA), and staff responsibilities related to complying with data privacy practices. The license holder provided this to SP4 in March 2024 and September of 2025; · sections 245A.65, 245A.66, and 626.557 and chapter 260E, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. The license holder provided this to SP4 in March 2024 and September of 2025; · 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; 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 ensure that SP2 through SP4 receives training on all the above topics that are required annually. The training must be documented in the staff person’s personnel record and must include the topic, date, instructor, and hours of training per subject area. 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.095, subdivision 5, paragraph (b). Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. a. The license holder did not maintain documentation for SP1 in their personnel record or elsewhere, sufficient to determine the date of SP1's first supervised direct contact with a person served by the program, and the date of first unsupervised direct contact with a person served by the program. b. The license holder did not maintain documentation for SP2 in their personnel record or elsewhere, sufficient to determine the date of SP2’s first supervised contact with a person served by the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245C.07, paragraph (f). Violation: For three staff persons whose records were reviewed (SP1, SP2 and SP4), did not comply with background study requirements. SP1 through SP3 provided direct support to people receiving services. The license holder submitted background studies for SP1, SP2, and SP4 under the license holder’s PCPO company, but did not affiliate the background studies to their 245D license roster in NetStudy 2.0 prior to having supervised contact and prior to providing unsupervised direct support. The license holder has since affiliated SP1, SP2, and SP4 to their 245D roster in NetStudy 2.0. 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
|
