Minnesota

February 6, 2026

Abdirisak Jimale, Authorized Agent

Evergreen Health Services

2920 Talmage Avenue Southeast Suite 240

Minneapolis, Minnesota 55414-7501

License Number: 1110219 (245D – HCBS)

CORRECTION ORDER

Dear Abdirisak Jimale:

On January 14, 2026, a licensing review of Evergreen Health Services, located at 2920 Talmage Avenue Southeast, Minneapolis, 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 (b).

Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not review and evaluate the individual abuse prevention plan (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 with the interdisciplinary team annually in 2024 or 2025. The IAPP was last reviewed by the interdisciplinary team in December 2023.

b. The license holder did not review P2’s IAPP with the interdisciplinary team annually in 2025. The IAPP was last reviewed by the interdisciplinary team in October 2024.

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

· review the IAPP for P1 and P2 with P1’s interdisciplinary team and P2’s interdisciplinary team;

· maintain documentation of this review in the service recipient record; and

· provide training to all staff that work with P1 and P2 on the IAPP and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area and the name of the trainer or instructor.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. 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 a written notice of the service recipient rights as required.

a. The license holder did not provide P1 or P1’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights annually in 2024 and 2025. P1 last received a written notice of their rights in November 2023.

b. The license holder did not provide P2 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. P2 last received a written notice of their rights in October 2024.

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

· provide P1 or P1’s legal representative and P2 with a written notice that identifies the service recipient rights and an explanation of those rights;

· maintain documentation of P1’s or P1’s legal representatives’ and P2’s receipt of a copy and an explanation of the rights in the service recipient record;

· conduct an audit of all service recipient records to identify any service recipients that did not receive a written notice identifying the service recipient rights and an explanation of those rights in the last 12 months; and

· provide any service recipients or legal representatives identified in the audit with a written notice identifying the service recipient rights and an explanation of those rights. Documentation of the receipt of a copy and an explanation of the rights must be maintained in the service recipient record as required.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not document health needs as required.

The license holder did not maintain documentation on how P1’s health needs would be met, including a description of the procedures the license holder would follow in order to:

· provide medication set up, assistance, or administration according to this chapter; and

· assist with or coordinate medical, dental, and other health service appointments.

Corrective Action Ordered: Within 30 days of receiving this order, you must document in the support plan addendum for P1 a description of the procedures you will follow in order to provide medication set up, assistance, or administration and assist with or coordinate medical, dental, and other health service appointments. You must provide training to all staff that work with P1 on these procedures and maintain documentation of this training in the personnel record, including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not implement medication administration procedures as required.

a. The license holder did not obtain written authorization from P1 or P1’s legal representative to administer medication or treatment prior to administering medication.

b. The license holder did not ensure the following information was documented in P1’s medication administration record (MAR):

· the information on the current prescription label or the prescribers current written or electronically recorded order or prescription that included a description of the medication or treatment to be provided, and the frequency or other information needed to safely and correctly administer medication or treatment to ensure effectiveness;

· information on any risks or other side effects that are reasonable to expect, and any contraindications to its use;

· the possible consequences if the medication or treatment is not taken or administered as directed;

· instructions on when and to whom to report the following:

· if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and

· the occurrence of possible adverse reactions to the medication or treatment;

· notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made; and

· notation of when a medication or treatment was started, administered, changed, or discontinued.

Corrective Action Ordered: You are no longer providing medication administration to P1, therefore, no corrective action is needed. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not review, and report medication issues as required.

a. The license holder did not ensure the information maintained in the MAR was reviewed at least every three months to identify medication administration errors. The license holder maintained MARs for P1 from January 2025 through July 2025. There was no documentation of those MARs being reviewed.

b. The license holder did not report to P1’s legal representative and P1’s case manager the refusal or failure of P1 to take or receive medication or treatment as prescribed as they occurred.

6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b).

Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments as required.

The license holder did not complete assessments of P1’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being including chronic medical conditions and self-administration of medication or treatment orders.

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

· complete an assessment of P1’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being including chronic medical conditions and self-administration of medication or treatment orders;

· review the results of the assessment with P1, P1’s legal representative, and P1’s case manager and maintain documentation of this review in the service recipient record; and

· provide training to all staff that work with P1 on the updated assessment of P1 and maintain documentation of this training in the personnel record including the date the training is provided, the number of hours per subject area, and the name of the trainer or instructor.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (d).

Violation: For one whose records were reviewed (P2), the license holder did not complete initial intensive service planning as required.

The license holder did not have a discussion with P2 and P2’s case manager within 45 days of service initiation of how technology might be used to meet P2’s desired outcomes.

Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

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

a. The license holder did not document the supports and methods to be implemented to support P1 and P2 and accomplish outcomes including:

· the methods or actions that will be used to support P1 and P2 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; and

o any equipment and materials required; and

· the measurable and observable criteria for identifying when the desired outcomes had been achieved and how data will be collected.

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

· document the supports and methods outlined above to be implemented to support P1 and P2 and accomplish outcomes; and

· provide training to all staff that work with P1 and P2 on the updated supports and methods to be implemented to support P1 and P2 and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.071, subdivision 5.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete service plan review and evaluation as required.

a. The license holder did not send P1’s support plan addendum to P1’s case manager within ten working days of the progress review meeting in 2024.

b. The license holder did not meet with P2 and P2’s case manager annually in 2025 as required according to P2’s support plan addendum. Additionally, the license holder did not have a discussion with P2’s support team of how technology might be used to meet P2’s outcomes at least once per year in 2025.

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

· meet with P2 and P2’s case manager to complete service plan review and evaluation to determine whether changes are needed to the service plan;

· update P2’s support plan addendum with any changes made as a result of the meeting and send the updated support plan addendum to P2 and P2’s case manager within ten working days of the meeting to obtain dated signatures documenting approval of the changes; and

· provide training to all staff that work with P2 on the updated support plan addendum and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

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

The license holder did not maintain progress or daily log notes that were recorded by the program for P1 and P2. The license holder initiated services for P1 in November 2023. The license holder initiated services for P2 in October 2024. The license holder maintained progress or daily log notes for P1 and P2 from December 2025 and January 2026.

Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.10, subdivision 3a.

Violation: For one person whose record was reviewed (P3), the license holder did not follow their policy and procedure regarding service termination as required.

The license holder did not follow their policy and procedure when terminating services for P3. The license holder terminated the services for P3 and did not:

· terminate the services for P3 for an allowable reason under 245D.10, subdivision 3a, paragraph (b), clauses (1) through (6);

· document actions taken to minimize or eliminate the need for termination including at a minimum:

o consultation with P3’s support team or expanded support team to identify and resolve issues leading to issuance of the termination notice; and

o a request to P3’s case manager for intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support P3 in the program;

· provide P3 with a service termination notice that included a summary of actions taken to minimize or eliminate the need for service termination and why these measures failed to prevent the termination; and

· provide the notice at least 60 days prior to the termination of services.

Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Rules, part 9544.0030, subpart 1

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

The license holder did not incorporate in writing to an existing treatment, service, or other individual plan the positive support strategies to be used when providing services to P1 and P2.

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

· incorporate in writing to the individual plan for P1 and P2, the positive support strategies to be used when providing services to P1 and P2;

· provide training to all staff that work with P1 and P2 on the positive support strategies incorporated into the service plans and maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor; and

· review the positive support strategies on an ongoing basis with P1 and P2 at least every six months to evaluate if changes are needed, and if so, make appropriate changes.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. Citation: Minnesota Rules, part 9544.0100, subpart 3.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain documentation of outcomes as required.

The license holder did not document the progress or lack of progress towards each outcome or goal for P1 and P2.

Corrective Action Ordered: Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

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

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

· 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;

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provision, 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.

The license holder hired SP1 on June 3, 2024. At the time of this review SP1 had not received this training.

b. The license holder did not provide orientation to SP2 in the following areas 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 section 245D.07, subdivision 1a, and how they apply to direct support services 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.

The license holder hired SP2 on January 11, 2024. At the time of this review, the license holder had not provided SP2 with orientation in these areas.

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

· provide SP1 and SP2 with the training outlined above;

· maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor;

· conduct an audit of all staff training records to identify any staff that have not received training in these areas;

· provide the missing training to any staff identified in the audit and maintain documentation of this training including the date the training is provided, the number of hours per subject area, and the name of the trainer or instructor in the personnel record;

· and maintain documentation of the results of the audit and corrective action taken in the program records.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

15. 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 the individual service recipient needs as required.

a. The license holder did not ensure SP1 reviewed and received instruction on medication administration procedures established for the person. Additionally, the license holder did not ensure that staff only performed medication administration after successfully completing medication administration training, from a training curriculum developed by a registered nurse or appropriate license health professional and included an observed skill assessment conducted by the trainer to ensure SP1 demonstrated the ability to safely and correctly follow medication procedures.

b. The license holder did not provide SP2 with the following training before having unsupervised direct contact with a person served by the program:

· orientation to the individual service recipient needs;

· the persons support plan or support plan addendum as it related to the responsibilities assigned to the license holder;

· the persons individual abuse prevention plan (IAPP), 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 SP2 with the training outlined above and maintain documentation of this training in the personnel record including the date the training is provided, the number of hours per subject area, and the name of the trainer or instructor. You are no longer providing medication administration services, therefore no corrective action is required for SP1. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training 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.

The license holder did not provide SP1 with the following trainings annually in 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 245D.04;

· sections 245A.65 and 626.557 and chapter 260E governing maltreatment reporting and service planning for vulnerable adults and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; and

SP1 last received training in these areas in June 2024.

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

· provide SP1 with the training outlined above;

· maintain documentation of this training in the personnel record including the date the training is completed, the number of hours per subject area, and the name of the trainer or instructor;

· conduct an audit of all staff training records to identify any staff that have not received annual training as outlined in 245D.09, subdivision 5;

· maintain documentation of the results of the audit and corrective action taken in the program records.

Compliance with this order will be reviewed at an upcoming compliance monitoring visit. 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 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.

Erin White, Home and Community Based Services Licensor

Licensing Division

Office of Inspector General

651-431-4821

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