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March 10, 2026 Elizabeth Namarra Holistic Array of Authentic Services, LLC 5851 Duluth Street Suite 302 Golden Valley, MN 55422 License Number: 1074999 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Elizabeth Namarra: On January 22, 2026, a licensing review of Holistic Array of Authentic Services, located at 5851 Duluth Street Golden Valley, 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.041, subdivision 4. Violation: The license holder did not ensure electronic records were maintained and stored to allow for review by DHS as required. The license holder did not ensure the use of electronic keeping did not limit the commissioner’s access to records as identified in section 245A.04, subdivision 5. The license holder utilized an electronic record keeping system and was unable to access records during the licensing review. Corrective Action Ordered: Within 60 days of receiving this order, you must ensure electronic records for all persons served are maintained and stored in a manner that allows for review by the commissioner. 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 1. Violation: The license holder did not establish written policies and procedures for internal and external reporting of suspected or alleged maltreatment as required. The license holder did not establish a reporting procedure that identified a secondary person or position, that shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. The license holder established a procedure that identified the same person for both the primary person or position and secondary person or position. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · review and revise your internal and external policies and procedures for reporting alleged or suspected maltreatment of vulnerable adults to include a secondary person or position to whom internal report may be made, is responsible for forwarding internal reports to the common entry point, and will ensure that, when required, internal reviews are completed; · provide persons served, or if applicable their legal representatives, with orientation of the updated policies and procedures; · provide staff with training on the updated policies and procedures; and · maintain documentation of staff training according to Minnesota Statues 245D.095. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.66, subdivision 1. Violation: The license holder did not establish written policies and procedures for internal and external reporting of suspected or alleged maltreatment of minors as required. The license holder did not establish a reporting procedure that met the requirements of section 142B.54, subdivision 1, that identified a primary person or position and a secondary person or position will ensure that, when required, internal reviews are completed. The license holder established a procedure that identified a primary position and secondary position, however the license holder was not able to identify who held the position or identified the position on the organizational chart established for the program. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · review and revise your internal and external policies and procedures for reporting alleged or suspected maltreatment of minors to include an identifiable primary person or position and secondary person or position that meets the requirements of this subdivision; · provide persons served that are minors, or if applicable their legal representatives, with orientation of the updated policies and procedures; · provide staff working with minors training on the updated policies and procedures; and · maintain documentation of staff training according to Minnesota Statues 245D.095. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not establish written policies and procedures for emergency use of manual restraint as required. The license holder did not develop, document, and implement a policy and procedures regarding the emergency use of manual restraints. The license holder maintained two contradictory policies and procedures on the emergency use of manual restraint, one policy that allowed the emergency use of manual restraint and one that did not allow the emergency use of manual restraint. Corrective Action Ordered: Within 60 days of receiving this order you must: · review and revise your emergency use of manual restraint policies and procedures consistently throughout your program; · provide all persons served, persons served legal representatives, person served case managers, and staff with review and instruction on your emergency use of manual restraint policies and procedures; and · maintain documentation of staff training according to Minnesota Statutes 245D.095. 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.11, subdivision 2. Violation: The license holder did not establish policies and procedures for intensive support services as required. The license holder did not establish the following policies and procedures to promote health and welfare: · safe medication assistance and administration; and · safe transportation. Corrective Action Ordered: Within 60 days of receiving this order you must: · establish, enforce, and maintain policies and procedures for safe medication assistance and administration; · establish, enforce, and maintain policies and procedures for safe transportation; · provide staff with training on the updated policies and procedures; and · maintain documentation of staff training according to Minnesota Statues 245D.095. 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 Rules, 9544.0030, subpart 1. Violation: For two of three persons whose records were reviewed (P2 and P3), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate with P2 and P3 whether the identified positive support strategies met the standards in subpart 2 at least every six months. The license holder completed this evaluation with P2 in June 2023, February 2024, and February 2025. The license holder completed this evaluation with P3 in October 2024, January 2025, and April 2025. Corrective Action Ordered: Within 30 days of receiving this order you must: · complete the evaluation identified above with P2 and P3 and based upon the results of this evaluation determine whether changes are needed in P2’s and P3’s positive support strategies used, and, if so, make appropriate changes; · provide P2’s and P3’s staff with training on the updated policies and procedures; and · maintain documentation of staff training according to Minnesota Statues 245D.095. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide orientation to the license holders maltreatment of vulnerable adults policies and procedures as required. The license holder did not provide P2, P3, and P3’s legal representative with an orientation to the internal and external reporting procedures within 72 hours of admission to the program. The license holder admitted P2 to the program on June 29, 2023, and provided this orientation on February 3, 2025. The license holder admitted P3 to the program on July 18, 2024, and provided this orientation on April 4, 2025 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 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder did not maintain an IAPP for P1 that included an accurate individualized assessment of P1’s susceptibility to abuse. P1’s IAPP stated that P1 was not susceptible to abuse. This assessment was not consistent with other information maintained in P1’s record. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and revise the IAPP for P1 to include an accurate assessment of P1’s susceptibility to abuse; · include a statement of measures, including specific actions, that will be taken to minimize the risk of abuse withing the scope of the licensed service; · review P1’s IAPP with their interdisciplinary team and maintain documentation of this review in P1’s record; and · provide training on P1’s revised IAPP to all staff persons that provided direct support services to 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. 9. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide services recipient rights as required. a. Within five days of service initiation, the license holder did not provide P3 or P3’s legal representative with a written notice that identified the services recipient rights and an explanation of those rights. The license holder initiated individualized home supports with family training on July 18, 2024, and in-home respite on October 20, 2024. At the time of this licensing review, the license holder had not provided P3 or P3’s legal representative with the service recipient rights. b. The license holder did not provide P2 with a written notice in 2024, that identified the service recipient rights and an explanation of those rights. The license holder maintained documentation of P2’s receipt of a copy and an explanation of those rights in June 2023 and February 2025. Corrective Action Ordered: Within 60 days of receiving this order you must provide P3 or P3’s legal representative with the service recipient rights and an explanation of those rights and maintain documentation according to Minnesota Statutes 245D.095. 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.05, subdivision 1. Violation: For three persons whose record were reviewed (P1 – P3), the license holder did not maintain documentation on how the person’s health needs would be met as required. "Medication setup" means the arranging of medications according to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration. a. The license holder was assigned the responsibility of meeting P1’s health service needs. The license holder did not maintain documentation on how P1’s health needs would be met, including a description the license holder would follow in order to provide medication assistance and assist with or coordinate medical, dental, and other health service appointments. b. The license holder was assigned responsibility for P2’s medication set up in P2’s support plan and the support plan addendum. The license holder did not maintain a medication administration record (MAR) for P2. c. The license holder was assigned responsibility for P3’s gastrostomy tube use. The license holder did not maintain documentation in P3’s record that included a description of the procedures the license holder would follow in order to use the gastrostomy tube safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 60 days of receiving this order you must: · maintain documentation on how P1’s health needs will be met, including a description the license holder would follow in order to provide medication assistance and assist with or coordinate medical, dental, and other health service appointments; · document in P2’s medication administration record (MAR): o dates of setup; o name of medication, o quantity of dose; o times to be administered; and o route of administration; · obtain written instructions from a licensed health professional on how to safely and correctly use P3’s gastrostomy tube safely and maintain the instructions in P3’s record; · review P1’s, P2’s, and P3’s updated support plan addendum with P1 and P1’s case manager, P2 and P2’s case manager, and P3 or P3’s legal representative and P2’s case manager; · provide P1’s, P2’s, and P3’s staff with training on the updated policies and procedures; and · maintain documentation according to Minnesota Statues 245D.095. 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.07, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not comply with the requirements of this chapter and the federal waiver plan The license holder provided individualized home supports with family training services to P3. The license holder hired and scheduled the mother of P3 to provide P3 with individualized home supports with family training. The license holder did not comply with the federal waiver plan requirements identified in the community-based services manual (CBSM) that relatives cannot be paid to provide individualized home supports with family training. Corrective Action Ordered: Immediately you must comply with the requirements identified in the CBSM. 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 Statutes, section 245D.07, subdivision 2. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide basic support services as required. a. The license holder did not review and revise P2’s preliminary support plan addendum within 60 days of initiating services. The license holder developed P2’s preliminary support plan addendum in June 2023. The license holder initiated a basic service with P2 in July 2023 and updated P2’s preliminary support plan addendum in February 2024.
b. The license holder did not complete a preliminary support plan addendum for P3 based on the support plan within 15 calendar days of service initiation for in-home respite services. The license holder initiated in-home respite services with P3 on October 20, 2024, and completed a support plan addendum on December 16, 2024. 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. 13. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not complete initial service planning for intensive support services as required. The license holder did not hold an initial planning meeting with P3’s case manager to determine the following based on information obtained from P3’s assessments: · the scope of the services to be provided to support the person's daily needs and activities; · the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; · the person'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 person; · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; and · 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 the person. Corrective Action Ordered: Within 60 days of receiving this order, you must: · meet with P3’s case manager to determine the above bullet points and update P3’s plan to reflect the results; · provide P3’s staff with training on P3’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. 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.071, subdivision 5. Violation: For one person whose record was reviewed (P3), the license holder did not meet the requirements for service plan review and evaluation as required. The license holder did not provide P3’s case manager the opportunity to participate in the ongoing review and development of the service plan and methods used to support P3 and accomplish outcomes. The license holder conducted a service plan review meeting with P3 and P3’s legal representative on April 4, 2025. Corrective Action Ordered: Within 60 days of receiving this order, you must: · meet with P3, P3’s legal representative, and P3’s case manager and review the requirements of this subdivision; · revise P3’s support plan addendum to reflect the results of this review; · provide P3’s staff with training on P3’s updated support plan addendum; and · maintain documentation according to Minnesota Statutes 245D.095. 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.095, subdivision 3. Violation: For three persons whose record were reviewed (P1-P3), the license holder did not maintain service recipient records as required. a. The license holder did not obtain a signed statement for P3 authorizing the license holder to act in a medical emergency when P3’s legal representative cannot be reached or is delayed in arriving. b. The license holder did not maintain progress or daily log notes for P1-P3. Corrective Action Ordered: Within 60 days of receiving this order you must obtain a signed statement from P3’s legal representative authorizing the license holder to act in a medical emergency when the legal representative for P3 cannot be reached or is delayed in arriving and keep the signed statement in P3’s recipient 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.10, subdivision 4. Violation: For three persons whose records were reviewed (P1 – P3), the license holder did not inform and provide copies of policies and procedures as required. a. The license holder did not inform and provide P1’s case manager copies of the following policies and procedures affecting a person’s rights under section 245D.04 within five days of service initiation: · grievance policy and procedure required under subdivision 2; · service suspension and termination policy and procedure required under subdivision 3; and · emergency use of manual restraints policy and procedure required under section 245D.061, subdivision 9, or successor provisions. b. The license holder did not inform and provide P2 and P2’s case manager copies of the following policies and procedures affecting a person’s rights under section 245D.04 within five days of each service initiation: · grievance policy and procedure required under subdivision 2; · service suspension and termination policy and procedure required under subdivision 3; and · emergency use of manual restraints policy and procedure required under section 245D.061, subdivision 9, or successor provisions. The license holder initiated P2’s services on July 2, 2023, March 14, 2025, and June 2, 2025. The license holder provided P2 the policies and procedures on June 29,2023. c. The license holder did not inform and provide P3, and P3’s case manager copies of the following policies and procedures affecting a person’s rights under section 245D.04 within five days of service initiation: · grievance policy and procedure required under subdivision 2; · service suspension and termination policy and procedure required under subdivision 3; · emergency use of manual restraints policy and procedure required under section 245D.061, subdivision 9, or successor provisions; and The license holder provided P3 the policies and procedures on April 4, 2025. Corrective Action Ordered: Within 60 days of receiving this order you must provide P1’s case manager, P2 and P2’s case manager, and P3’s case manager with copies of the policies identified above for the services initiated and maintain documentation according to Minnesota Statutes 245D.095. 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 245A.65, subdivision 3. Violation: For one of five staff persons (SP1) whose record was reviewed, the license holder did not provide an orientation to vulnerable adult maltreatment prevention and reporting within 72 hours of first providing direct contact services as required. SP1 was hired on June 6, 2023. SP1 began providing direct contact services on the same day. The license holder did not provide an orientation to SP1 on vulnerable adult maltreatment reporting within 72 hours of SP1 first providing direct contact services. The license holder provided this training to SP1 on May 12, 2024. Corrective Action Ordered: On an ongoing basis, you must ensure that all staff are oriented to vulnerable adult maltreatment reporting and are provided annual review as required in this subdivision. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation training as required. a. SP1 was hired on June 6, 2023. The license holder did not provide SP1 with the following orientation training within 60 days of hire: · the job description and how to complete specific job functions including: o responding to and reporting incidents as required in Minnesota Statutes, section 245D.06, subdivision 2; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2. This was provided to SP1 on May 12, 2024;and · the license holder’s policies and procedures, including: o temporary service suspension and termination;2024; o drug and alcohol prohibition policy; and o emergency use of manual restraint; · the principles of person centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services provided by the staff; · 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. b. SP2 was hired on September 7, 2022. The license holder did not provide SP2 with the following orientation training within 60 days of hire: · the principles of person centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services provided by the staff; · 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. c. SP3 was hired on October 25, 2024. The license holder did not provide SP3 with the following orientation training within 60 days of hire: · the principles of person centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services provided by the staff; · 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 60 days of receiving this order, you must provide SP1 -SP3 with the above-mentioned training and maintain documentation of staff training according to Minnesota Statutes 245D.095. 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.09, subdivision 4a, paragraph (d). Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation to individual needs as required. a. The license holder was assigned the responsibility of medication set up for P2. The license holder did not review and provide instruction to SP2 on a medication setup training, from a training curriculum developed by a registered nurse of appropriate license health professional and on medication set up and assistance procedures for P2. b. The license holder was assigned the responsibility of medication administration for P3. The license holder did not review and provide instruction to SP3 on a medication administration training, from a training curriculum developed by a registered nurse of appropriate license health professional and on medication set up and assistance procedures for P3. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and provide instruction to SP2 on medication set up procedures for P2 and provide SP2 with a medication setup training, from a training curriculum developed by a registered nurse of appropriate licensed health professional which incorporates an observed skill assessment conducted by the trainer to ensure SP2 demonstrates the ability to safely and correctly follow medication procedures; · review and provide instruction to SP3 on medication administration procedures for P3 and provide SP3 with a medication setup training, from a training curriculum developed by a registered nurse of appropriate licensed health professional which incorporates an observed skill assessment conducted by the trainer to ensure SP3 demonstrates the ability to safely and correctly follow medication procedures; and · maintain documentation according to Minnesota Statutes 245D.095. 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. 20. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For three staff persons whose record were reviewed (SP1-SP3), 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. a. The license holder did not provide SP1 and SP2 with the following annual trainings in 2024 and 2025: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Ace of 1996 (HIPPA), 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; and · 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. b. The license holder did not provide SP3 with the following annual trainings in 2025: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Ace of 1996 (HIPPA), 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; and · 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. Corrective Action Ordered: Within 60 days of receiving this order you must provide SP1-SP3 with the trainings identified above and maintain documentation according to Minnesota Statutes 245D.095. 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. 21. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (b). Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not maintain personnel records as required. a. The license holder did not maintain accurate documentation in SP1’s personnel record or elsewhere, sufficient to determine the date of first supervised and unsupervised direct contact with a person served. Additionally, the license holder did not maintain in SP1’s personnel record the number of training hours of per subject area. b. The license holder did not maintain in SP2’s and SP3’s personnel record the date of training, number of hours of per subject area, and name of trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain the following training information in each staff person’s personnel record as required in this subdivision: · date of training; · number of hours of per subject area; and · name of 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. 22. Citation: Minnesota Statutes, section 245D.081, subdivision 2.
Violation: For one staff person whose record was reviewed (SP4), the license holder did not ensure that the person was competent to perform designated coordinator responsibilities. The license holder hired SP4 to act in a role with responsibilities related to the supervision, support and evaluation of services provided by the license holder. The license holder did not ensure SP4 was competent to perform the required designated coordinator duties through education, training, and work experience requirements. The license holder did not ensure SP4 minimally had: · a baccalaureate degree in a field related to human services, and one year of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older; · an associate degree in a field related to human services, and two years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older; · a diploma in a field related to human services from an accredited postsecondary institution and three years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older; or · a minimum of 50 hours of education and training related to human services and disabilities; and · four years of full-time work experience providing direct care services to persons with disabilities or persons age 65 and older under the supervision of a staff person who meets the qualifications of a designated coordinator. Corrective Action Ordered: Within 30 days of receiving this order, you must: · identify a designated coordinator, other than SP4, for your program that meets requirements in section 245D.081, subdivision 2; 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. 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 23. Citation: Minnesota Statutes, section 245D.081, subdivision 1. Violation: For one staff person whose record was reviewed (SP5), the license holder did not provide program coordination, evaluation, and oversight as required. SP5 did not ensure: · the staff person(s) identified as designated coordinator for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2; and · the staff person(s) identified as designated manager for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 3. Corrective Action Ordered: Within 30 days of receiving this order you must: · maintain a signed document that the designated coordinator(s) and designated manager(s) have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3; and maintain documentation in staff records according to Minnesota Statutes 245D.095; · ensure coordination of service delivery and evaluation for each person served by the program as identified in subdivision 2; and · ensure program management and oversight that includes evaluation of the program quality and program improvement for services provided by the license holder as identified in subdivision 3. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at coty.aust@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Coty Aust Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Coty Aust, HCBS Licensor Licensing Division Office of Inspector General 651-431-4605
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