Minnesota

NOTICE: The Amended Correction Order supersedes the original Correction Order dated February 24, 2026. This document is amended to correct the date the licensing review was conducted and to remove medication names in part a of citation 8.

Date issued: February 24, 2026

Date reissued: March 10, 2026

Hussein Mohamed, Authorized Agent

Living Hope LLC

5400 Opportunity Court Suite 110

Hopkins, MN 55343

License Number: 1104769 (245D – HCBS)

Licensing Investigation Report Numbers: 202509553, 202510601, and 202511377

CORRECTION ORDER

Dear Hussein Mohamed:

On January 7-9, 12, and 16, 2026, a licensing review of Living Hope LLC, located at 5400 Opportunity Court, Hopkins, 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 two of six persons whose records were reviewed (P3 and P4), the license holder did not provide orientation to and enforce written policies and procedures related to suspected or alleged maltreatment as required.

a. The license holder did not enforce the program’s policies and procedures related to suspected or alleged maltreatment when the license holder did not ensure that internal reviews were completed within 30 calendar days of the program submitting the following maltreatment reports concerning P3:

• August 8, 2025;

• August 19, 2025;

• September 22, 2025;

• December 2, 2025;

• December 23, 2025; and

• December 26, 2025.

Additionally, the license holder did not report maltreatment to Minnesota Adult Abuse Reporting Center (MAARC) within 24 hours of an incident involving P3. The incident occurred on December 24, 2025, and the license holder reported to MAARC on December 26, 2025.

b. The license holder initiated integrated community supports (ICS) services for P4 on August 19, 2024. The license holder did not provide P4 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder provided P4 with this orientation on July 28, 2025.

Corrective Action Ordered: Withing 60 days of receiving this order, you must conduct internal reviews for P3’s incidents of suspected or alleged maltreatment listed above. The internal reviews must include the following:

· an evaluation of:

o whether related policies and procedures were followed;

o whether the policies and procedures were adequate;

o whether there is a need for additional staff training;

o whether the reported event is similar to past events with the person, or the services involved;

o whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services; and

· based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the license holder, if any.

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 245A.65, subdivision 2.

Violation: For one person whose record was reviewed (P4), the license holder did not establish and enforce abuse prevention plans as required.

a. The license holder did not provide P4 with orientation to the program abuse prevention plan (PAPP) within 24 hours of admission to ICS services. The license holder provided P4 with this orientation on July 28, 2025.

b. The license holder did not develop an individual abuse prevention plan (IAPP) for P4 prior to or upon service initiation of ICS services. The license holder developed an IAPP for P4’s ICS services on July 28, 2025.

The license holder initiated employment development services on January 28, 2025 for P4. The license holder did not develop an IAPP for P4 prior to or upon service initiation of employment development services. The license holder developed an IAPP for P4’s employment development services on January 31, 2025.

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

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

Violation: For one person whose record was reviewed (P4), the license holder did not provide service recipient rights as required.

The license holder did not provide P4 with a written notice that identified the service recipient rights, and explanation of those rights within five working days of service initiation for ICS. The license holder provided P4 with this notice on July 28, 2025.

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

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

Violation: For one person whose record was reviewed (P3), the license holder did not ensure the exercise and protection of a person’s rights as required.

The license holder did not ensure the exercise and protection of P3’s right to privacy. The license holder documented the staff were responsible for the following for P3:

· monitoring all mail deliveries;

· conducting bedroom checks;

· maintaining a physical presence in P3’s room all night while they were sleeping; and

· conducting a physical safety check when they entered the home including checking their bag, hair, shoes and socks.

Additionally license holder had the doorknob to bathroom removed so that staff could provide visual supervision while P3 was using bathroom.

Corrective Action Ordered: Immediately, you must:

· restore P3’s right to privacy regarding maintaining physical supervision while P3 is sleeping and visual supervision while they are utilizing the bathroom;

· meet with P3’s team to determine if a restrictions of P3’s rights is necessary to ensure P3’s health, safety, and well-being;

· restore P3’s right to privacy for the remainder of the above mentioned situations if P3’s team determines a rights restriction is not necessary; and

· if P3’s team does determine a rights restriction is necessary, you must maintain the following documentation:

o the justification for the restriction based on an assessment of P3's vulnerability related to exercising the right without restriction;

o the objective measures set as conditions for ending the restriction;

o a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by P3 and case manager; and

o signed and dated approval for the restriction from P3. A restriction may be implemented only when the required approval has been obtained. Approval may be withdrawn at any time. If approval is withdrawn, the right must be immediately and fully restored.

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.04, subdivision 3, paragraph (c).

Violation: For one person whose record was reviewed (P1), the license holder did not implement a rights restriction as required.

The license holder did not implement a rights restriction for P1 as required. The license holder did not document the objective measures set as conditions for ending P1’s rights restriction.

Corrective Action Ordered: Within 60 days of receiving this order, you must audit all person served records to ensure the above has been completed when applicable and maintain documentation of the audit results. P1 is no longer receiving services from the license holder, therefore no corrective action is 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.

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

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not document health needs as required.

The license holder was responsible for administration of P1’s and P3’s psychotropic as needed (PRN) medications. The license holder did not maintain documentation on how P1’s and P3’s health needs would be met, including a description of the procedures the license holder would follow in order to safely administer psychotropic PRN medications.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P1’s and P3’s support plan addendum to include documentation on how their health needs will be met in regards to the administration of psychotropic PRN medications;

· audit all person served records to ensure the above has been documented when applicable;

· maintain documentation of the audit results;

· provide all staff who have direct contact with P1 and P3 on the revised support plan addendums;

· maintain documentation of the training in each staff’s personnel records.

P1 is no longer receiving services from the license holder, therefore no corrective action is 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.

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

Violation: For three persons whose records were reviewed (P1-P3), the license holder did not document medication setup as required.

The license holder assumed responsibility for medication setup for P1, P2 and P3. The license holder did not document the dates of setup in P1’s, P2’s and P3’s medication administration record.

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

8. 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 procedures as required.

a. The license holder was responsible for medication administration for P1. The license holder did not implement the following medication administration procedures:

· The license holder did not maintain the information on the current prescription label or the prescribers current written or electronically record order or prescription prior to starting two medications.

· The license holder did not ensure notation of a occurrence of a dose of medication not being administered as prescribed, whether by error by the staff or by refusal by the person.

· The license holder did not document on P1’s MAR instructions on when and to whom to report:

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

o the occurrence of possible adverse reactions to the medication or treatment.

b. The license holder was assigned responsibility for medication administration for P3. The license holder did not implement medication administration procedures to ensure P3 took medications as prescribed:

· The license holder did not obtain written authorization from P3 prior to administering medications to P3. The license holder initiated P3’s services in August 2024 and the license holder obtained written authorization from P3 in August 2025. During this time the license holder administered daily medications to P3.

· P3 was prescribed an antibiotic on November 21, 2025, that P3 was to begin immediately. At the time of licensing review on January 16, 2026, the license holder did not maintain any documentation that this medication was administered.

· P3 was prescribed a new medication to be started on September 16, 2025. The license holder did not ensure that a notation of this medication was documented in P3’s MAR on September 16, 2025, and September 17, 2025.

· The license holder did not ensure that a notation of P3’s PRN pain medication was documented in P3’s MAR on November 11, 2025, December 23, 2025, and January 1, 2026.

Additionally, the license holder did not document in P3’s MAR instruction 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.

Corrective Action Ordered: Within 60 days of receiving this order, you must document on P3’s MAR instruction 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

P1 is no longer receiving services from the license holder, therefore no corrective action is ordered. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. 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.05, subdivision 4.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not review and report medication and treatment issues as required.

a. The license holder did not report 1,100 or more refusals or failures to take or receive medications and treatment as prescribed by P1 as they occurred to P1’s legal representative and case manager from July 2025 through December 2025. The license holder made reports to the case manager on a weekly basis, not as medication refusals occurred.

Additionally, the license holder did not complete MAR reviews for P1 as required:

· The license holder did not complete a review of P1’s MAR for the months of July and August.

· The license holder did not complete an accurate MAR review for P1’s MAR for September, October and November 2025. The license holder documented no medications errors were identified. DHS licensors identified at least 1,100 or more errors during this time period.

The license holder did not develop and implement a plan to correct this pattern of medication administration errors.

b. The license holder did not report 1900 or more refusals or failure to take or receive medications and treatments as prescribed by P3 as they occurred to P3’s case manager from August 2025 through December 2025. The license holder made reports to the case manager on a weekly basis, not as medication refusals occurred.

Additionally, the license holder did not accurately complete MAR reviews for P3’s MAR for September, October and November 2025. The license holder documented no medication errors were identified. DHS licensors identified at least 1,200 medication errors during this time period.

Corrective Action Ordered: Withing 60 days of receiving this order, you must:

· complete a review of P3’s MAR from August 2025 through December 2025 to accurately identify all medication errors, including all refusals or failures to take or receive medications as prescribed;

· report all medication errors for P3 from August 2025 through December 2025 to P3’s case manager;

· maintain documentation of notifications regarding medication errors in P3’s support plan addendum;

· develop and implement a plan to correct P3’s pattern of medication administration or documentation errors;

· maintain documentation of this plan in P3’s support plan addendum;

· provide all staff working with P3 training on the developed plan;

· audit all person served medication administration records to ensure all medication errors have been identified and reported to their legal representative (when applicable) and case managers; and

· maintain documentation of the audit results.

10. Citation: Minnesota Statutes, section 245D.051, subdivision 1.

Violation: For one person whose record was reviewed (P3), 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 P3 including psychotropic medications. The license holder did not document a description of the target symptoms that each psychotropic medication was to alleviate for P3.

Corrective Action Ordered: Within 60 days of receiving this order, you must maintain documentation in P3’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 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.06, subdivision 1 and 245D.11, subdivision 2.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the protection standards of incident response, reporting, and enforcing policies and procedures regarding incidents as required.

a. The license holder did not maintain information about incidents on the following dates within 24 hours of an incident that occurred while services were provided to P1:

· Incident occurred on November 1, 2025, and an incident report was completed on November 3, 2025;

· Incident occurred on September 27, 2025, and an incident report was completed on September 29, 2025;

· Incident occurred on December 13, 2025, and an incident report was completed on December 15, 2025;

· Incident occurred on December 20, 2025, and an incident report was completed on December 22, 2025;

· Incident occurred on December 31, 2025, and no incident report was completed.

The license holder did not maintain information about the following incidents within 24 hours of an incident that occurred while services were provided to P3:

· Incident occurred on September 8, 2025, and an incident report was completed on September 11, 2025;

· Incident occurred on September 12, 2025, and no incident report was completed;

· Incident occurred on September 16, 2025, and an incident report was completed on September 22, 2025;

· Incident occurred on December 24, 2025, and no incident report was completed; and

· Incident occurred on December 31, 2025, and no incident report was completed.

b. The license holder did not enforce the license holder’s, “Policy and Procedure on Responding to and Reporting Incidents” when they did not maintain incident reports for P1, P2 and P3 that included:

· whether a person's support plan addendum or program policies and procedures were implemented as applicable; and

· the name of the staff person or persons who responded to the incident or emergency.

c. The license holder did not enforce the license holder’s, “Policy and Procedure on Reviewing Incidents and Emergencies” when they did not identify patterns and implement corrective action for incidents involving P2 on September 11, 2025, September 19, 2025 October 9, 2025, December 22, 2025, and January 3, 2026.

d. The license holder did not report incidents on the following dates to P1’s legal representative and case manager within 24 hours of an incident that occurred while services were provided to P1:

· September 27, 2025. Case manager was notified on September 29, 2025;

· October 17, 2025. Case manager was notified on October 20, 2025;

· November 1, 2025. Case manager was notified on November 3, 2025;

· December 13, 2025. Case manager was notified on December 15, 2025; and

· December 20, 2025. Case manager was notified on December 22, 2025;

The license holder did not report incidents on the following dates to P3’s case manager within 24 hours of an incident that occurred while services were provided to P3:

· September 8, 2025;

· September 16, 2025;

· September 23, 2025;

· November 29, 2025. P3’s case manager was notified on December 4, 2025; and

· December 31, 2025.

e. The license holder did not report serious injuries that P1 sustained to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental health and Developmental Disabilities within 24 hours of the serious injury, or receipt of information that the serious injury occurred on the following dates September 27, 2025 and November 30, 2025. At the time of licensing review the license holder had not completed these reports.

The license holder did not report serious injuries that P3 sustained to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental health and Developmental Disabilities within 24 hours of the serious injury, or receipt of information that the serious injury occurred on the following dates:

· October 13, 2025;

· October 19, 2025; and

· December 24, 2025.

Additionally, the license holder did not conduct internal reviews for P3’s incidents of serious injuries to identify incident patterns, and to implement corrective action as necessary to reduce occurrences.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review all information maintained in P3’s record from August 2025 to current to determine when incidents, including serious injuries, occurred;

· maintain an incident report for each of the incidents, including serious injuries that are identified;

· report all incidents to P3’s case manager;

· report serious injuries to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental Health and Developmental Disabilities; and

· conduct internal reviews for P3’s incidents of serious injuries. The internal reviews must include the following:

o an evaluation of:

· whether related policies and procedures were followed;

· whether the policies and procedures were adequate;

· whether there is a need for additional staff training;

· whether the reported event is similar to past events with the person, or the services involved;

· whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services; and

o based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the license holder, if any.

12. Citation: Minnesota Statutes, section 245D.07, subdivisions 1 and 1a.

Violation: For one person whose record was reviewed (P3), the license holder did not provide services as assigned in the support plan and support plan addendum.

The license holder maintained documentation in P3’s support plan addendum that staff would provide the following services and documention:

· grounding activities;

· food and hydration intake;

· water temperatures;

· shower duration; and

· frequency of bathroom use.

The license holder did not maintain documentation of these services being provided in P3’s support plan addendum. Additionally, the license holder maintained a support plan provided by P3’s case manager in which it stated that staff would document hourly on P3’s cares. During the licensing review, the license holder stated they were unaware of this and did not document hourly.

Corrective Action Ordered: Immediately, you must provide services to P3 as assigned in P3’s support plan and support plan addendum. 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 Statutes, section 245D.07, subdivision 2, paragraph (c).

Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not complete service planning requirements for basic support services as required.

The license holder did not review and revise P1’s and P5’s support plan addendum within 60 calendar days of service initiation to document the services that would be provided including how, when and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services.

Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P5’s preliminary support plan addendum to document the information detailed above. Additionally, you must provide orientation on the updates to P5’s support plan addendum to all staff that provide direct support to P5. P1 is no longer receiving services from the license holder, therefore no corrective action is ordered for P1. 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.07, subdivision 1a.

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 documented that P1 requires a staffing ratio of two-to-one 24 hours a day. The license holder documented on the following days that P1 did not have staff supervision:

· September 27, 2025

· October 15, 2025;

· November 1, 2025;

· November 26, 2025;

· November 28, 2025;

· November 29, 2025; and

· November 30, 2025.

Corrective Action Ordered: P1 is no longer receiving services from the license holder, therefore no corrective action is ordered. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not complete assessments as required.

a. The license holder did not complete accurate assessments on P3’s ability to self-manage seizures. The license holder documented in P3’s assessment that P3 had no seizures, and P3 had a seizure disorder.

b. The license holder did not complete assessments of P4’s overall strengths, functional skills and abilities, and behaviors and symptoms in the following areas within 45 days of service initiation for ICS:

· P4'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;

· P4'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

· P4'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.

This was completed on July 1, 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P3’s assessments to accurately assess P3’s ability to self-manage seizures;

· review P3’s revised assessments with P3’s expanded support team and maintain documentation of this review in P3’s support plan addendum;

· provide training on the revised assessments to all staff who provide direct support to P3; and

· maintain documentation of this training in each staff person’s personnel record.

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.071, subdivision 3.

Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not complete initial service planning as required for intensive support services.

a. The license holder did not have a discussion at the initial planning meeting of how technology might be used to meet P3’s desired outcomes.

b. The license holder did not complete a preliminary support plan for P4 within 15 days of service initiation for ICS.

The license holder did not meet with P4, P4’s case manager, and other members of the support team or expanded support team within 45 days of service initiation for ICS to complete assessments in the following areas:

· the scope of the services to be provided to support P4's daily needs and activities;

· P4's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

· P4's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule;

· whether the current service setting is the most integrated setting available and appropriate for the P4;

· how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for P4; and

· a discussion of how technology might be used to meet P4's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include:

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.

The license holder completed the above assessments and reviews with P4 and P4’s case manager on July 28, 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· discuss with P3, P3’s case manager, and members of P3’s support team about how technology might be used to meet the person’s desired outcomes; and

· document a summary of this discussion in P3’s support plan addendum that includes the following:

· 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.

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.

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

Violation: For three persons whose record were reviewed (P3-P5), the license holder did not document service outcomes and supports as required.

a. The license holder did not develop a service plan for P3 that documented the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a that included:

· 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 outcome has been achieved and how data will be collected; and

· the date by which progress towards accomplishing the outcomes will be reviewed and evaluated.

b. The license holder did not develop a service plan for P4 that documented the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a that included:

· the methods or actions that will be used to support the person 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, any equipment and materials required, and techniques that are consistent with the person’s communication mode and learning style;

· the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will 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.

The license holder developed a service plan for P4 that documented service outcomes and the above mentioned supports on July 28, 2025.

c. The license holder did not document the supports and methods to be implemented to support P5 including:

· 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; and

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

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· develop and document supports and methods for P3’s and P5’s desired outcomes identified above;

· submit to and obtained dated signatures from P3’s and P5’s case manager for approval;

· provide orientation to P3’s and P5’s documented supports and methods to all staff who provide direct support services to P3 and P5; and

· implement the supports and methods for P3’s and P5’s desired outcomes and track data related to their outcomes.

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.

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

Violation: For one person whose record was reviewed (P3), the license holder did not complete service planning review and evaluation for intensive services as required.

The license holder did not document the following discussions required at least once per year in 2025 for P3:

· how technology might be used to meet P3’s desired outcomes; and

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

Corrective Action Ordered: Within 60 days of receiving this order, you must discuss with P3, P3’s case manager, and members of P3’s support team about options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. Corrective action for regarding how technology might be used to meet P3’s desired outcomes is addressed in citation 16. 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.

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

Violation: For two persons whose records were reviewed (P1 and P6), the license holder did not enforce their policy and procedures for service termination as required as required.

a. The license holder did not provide a service termination to P1 60 days prior to terminating services. The license holder provided the service termination on December 30, 2025, and documented the effective date for P1’s service termination as December 29, 2025. The license holder documented that this termination was given in conjunction with a notice of temporary service suspension; however, the license holder told DHS licensors that this did not happen.

b. The license holder did enforce their policy and procedures for service termination for P6. The license holder documented reason for termination as necessary for the person’s welfare and the license holder could not meet the P6’s needs. This is not consistent with documentation on the termination that documented the reason for termination was because P6 would require fewer direct hours care than originally anticipated.

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

20. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not provide written or electronic copies of policies and procedures as required.

a. The license holder did not inform P2’s case manager of the policies and procedures affecting a person’s rights and provide copies of those policies and procedures, within five working days of service initiation for crisis respite:

· grievance policy;

· temporary service suspension policy;

· service termination policy;

· emergency use of manual restraints policy; and

· data privacy policy.

The license holder informed and provided P2’s case manager the above-mentioned policies on September 29, 2025.

b. The license holder did not inform P4 or P4’s case manager of the policies and procedures affecting a person’s rights, and provide copies of those policies and procedures, within five working days of service initiation for ICS:

· grievance policy;

· temporary service suspension policy;

· service termination policy;

· emergency use of manual restraints policy; and

· data privacy policy.

The license holder informed and provided P4 and P4’s case manager the above-mentioned policies on July 28, 2025.

c. The license holder did not inform P4 or P4’s case manager of the policies and procedures affecting a person’s rights, and provide copies of those policies and procedures, within five working days of service initiation for employment development services:

· grievance policy;

· temporary service suspension policy;

· service termination policy;

· emergency use of manual restraints policy; and

· data privacy policy.

The license holder informed and provided P4 and P4’s case manager the above-mentioned policies on February 21, 2025.

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

21. Citation: Minnesota Statutes, section 245D.26, subdivision 4.

Violation: For one person whose record was reviewed (P3), the license holder did not comply with sanitation and health requirements in a community residential setting.

The license holder did not comply with the requirements of the Minnesota Clean Indoor Air Act, sections 144.411 to 144.417. The license holder maintained documentation in P3’s support plan addendum that P3 consistently smoked in the garage of the residence.

Corrective Action Ordered: Immediately, you must ensure the program complies with the requirements of the Minnesota Clean Indoor Air Act. On an ongoing basis, you must maintain compliance as required in this subdivision.

22. Citation: Minnesota Rules, 9544.0030, subpart 1.

Violation: For one person whose record was reviewed (P3), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate the identified positive support strategies with P3 at least every six months.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· evaluate the identified positive support strategies with P3 at least every six months and document the evaluation in P3’s support plan addendum; 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.

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 subpart

23. Citation: Minnesota Rules, part 9544.0080, subpart 1.

Violation: For one person whose record was reviewed (P4), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required.

At the time of service initiation for ICS, on August 19, 2024, the license holder did not obtain a written acknowledgement from P4 indicating that P4 had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, section 245D.04. The license holder obtained a written acknowledgement from P4 on July 28, 2025.

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

24. Citation: Minnesota Rules, part 9544.0110.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not report the use of restrictive interventions and incidents as required.

a. The license holder did not use the behavior intervention form required by the commissioner to report behavioral incidents involving P1 that resulted in calls to 911 on the following dates:

· September 21, 2025;

· September 27, 2025;

· October 17, 2025;

· November 30, 2025;

· December 13, 2025;

· December 20, 2025; and

· December 27, 2025;

b. The license holder did not use the behavior intervention form required by the commissioner to report behavioral incidents involving P3 that resulted in calls to 911 on the following dates:

· August 11, 2025;

· August 26, 2025;

· October 13, 2025;

· October 19, 2025;

· November 12, 2025;

· November 16, 2025;

· November 19, 2025;

· December 18, 2025;

· December 24, 2025; and

· December 30, 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must use the behavior intervention report form required by the commissioner to report the above-mentioned incidents that occurred with P1 and P3. 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 subpart

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

Violation: For three of seven staff persons whose records were reviewed (SP2, SP4, SP5), the license holder did not provide annual review of the internal and external reporting procedures related to suspected or alleged maltreatment or the license holder’s program abuse prevention plan.

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 ensure SP2 and SP5 received annual training and review of the internal and external reporting procedures related to suspected or alleged maltreatment in 2025. SP2 most recently completed this training in July 2024. SP4 most recently completed this training in June 2024.

Additionally, the license holder did not ensure SP2, SP4, and SP5 completed an annual review of the license holder’s PAPP in 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· provide SP2, SP4, and SP5 the above-mentioned training;

· audit all staff personnel records to ensure the above training has been completed;

· maintain documentation of the audit results; and

· based on the results of the audit ensure the above training is provided and completed all staff who have not completed the training.

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.

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

Violation: For three staff persons whose records were reviewed (SP1, SP3, and SP5), the license holder did not provide and ensure completion of orientation training as required.

The license holder did not ensure SP1, SP3 and SP5 received basic first aid training within 60 calendar days of hire.

Corrective Action Ordered: Corrective action for SP1, SP3 and SP5 is addressed in citation 26. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For four staff persons whose records were reviewed (SP1, SP2, SP4, and SP5), the license holder did not provide and ensure completion of annual training as required.

a. The license holder did ensure SP1 received annual training in 2025 on basic first aid.

b. The license holder did not ensure SP2, SP4, and SP5 received annual training in 2025 in the following areas:

· data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices;

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

· the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person;

· the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 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, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe;

· basic first aid; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

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

· provide SP1, SP2, SP4, and SP5 with the above-mentioned required annual training; and

· audit all staff personnel records for all staff to ensure all staff have received annual training on all of the required topics; and

· based on the results of the audit, provide annual training to all staff who have not received training on any of required annual training topics.

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.

28. Citation: Minnesota Statutes, section 245D.081, subdivisions 2.

Violation: For one staff person whose record was reviewed (SP7), the license holder did not ensure the designated coordinated were competent to perform the required duties.

The license holder did not ensure SP7 was competent to perform the required duties identified in paragraph (a) through education, training and work experiences.

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

· identify a designated coordinator, other than SP7, for your program that meets requirements in section 245D.081, subdivisions 2 and 3;

· submit the name and verifiable qualifications of the individual who will be acting in the designated manager role to your licensor for approval; and

· maintain a signed document that the designated coordinator has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s 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

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.

Robert Romani, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-3658

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