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March 12, 2026 Mahad Mohamed Ali, Authorized Agent Good Hands Home Health Care LLC 15633 Dakota Avenue Savage, Minnesota 55378 License Number: 1108258 (245D – HCBS) CORRECTION ORDER Dear Mahad Mohamed Ali: On March 3, 2026, a licensing review of Good Hands Home Health Care, located at 7401 Metro Boulevard, Suite 545, Edina, 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 three of four persons whose records were reviewed (P1, P2, and P4), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours as required. The license holder did not provide P1, P2, and P4 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours of admission. The license holder admitted P1’s services on February 1, 2025. The license holder admitted P2’s services on September 1, 2023, and provided this orientation to P2 on September 6, 2023. The license holder admitted P4’s services on April 1, 2025, and provided this orientation to P4 on August 6, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment and maintain documentation of this orientation in P3’s service recipient record as required in section 245D.095, subdivision 3, paragraph (b). Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not establish and enforce abuse prevention plans as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder did not develop an individual abuse prevention plan (IAPP) for P1, P2, and P4 as part of the initial individual program plan or service plan prior to or upon service initiation. The license holder initiated P1’s services on February 1, 2025, and developed an IAPP for P1 on May 13, 2025. The license holder initiated P2’s services on September 1, 2023, and developed an IAPP for P2 on September 6, 2023. The license holder initiated P4’s services on April 1, 2025, and developed an IAPP for P4 on August 6, 2025. b. The license holder did not review P2’s IAPP annually in 2024. The license holder reviewed P2’s IAPP in December 2025. c. The license holder did not provide an orientation to the program abuse prevention plan (PAPP) to P1 and P4 within 24 hours of admission. The license holder initiated P1’s services on February 1, 2025, and P4’s services on April 1, 2025. The license holder provided P4 with orientation to the PAPP on August 6, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with an orientation to the PAPP. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not provide the service recipient rights as required. a. The license holder did not provide P1, P2 and P4 with a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation. The license holder initiated P1’s services on February 1, 2025, and provided rights to P1 on May 13, 2025. The license holder initiated P2’s services on September 1, 2023, and provided rights to P2 on January 18, 2024. The license holder initiated P4’s services on April 1, 2025, and provided rights to P4 on August 6, 2025. 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. The license holder provided this to P2 in October 2024 and December 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · audit all service recipient records to ensure they have received an explanation and written notice that identifies the service recipient rights in subdivisions 2 and 3; and · if any service recipient has not received these rights, or has not received these rights in the last annual year, provide these rights to the person or their legal representative, if applicable; · maintain documentation of the person or their legal representative’s receipt of these rights as required in Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b); and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P4), the license holder did not maintain documentation of health needs as required. The license holder was assigned responsibility of meeting P4’s health needs. The license holder did not maintain documentation of how P4’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication set up and assistance according to this chapter. The license holder maintained information in P4’s record that documented the license holder’s responsibility to set up P4’s medications on a weekly basis and provide daily reminders. The license holder informed DHS licensors that they no longer set up P4’s medications. This information was inconsistent with the documentation of how P4’s health needs would be met; and · monitor health conditions according to written instructions from a licensed health professional. The license holder maintained information in P4’s record that documented P4 has a history of seizures. The license holder did not maintain a description of the procedures to follow to monitor for P4’s seizures. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation of how P4’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication assistance and monitor health conditions according to written instructions from a licensed health professional. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For one person whose record was reviewed (P4), the license holder did not maintain documentation of medication set up as required. For the purposes of this subdivision, "medication setup" means the arranging of medications according to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration when the license holder is assigned responsibility in the support plan or the support plan addendum. The license holder was assigned responsibility for setting up P4’s medications in P4’ support plan addendum at the time P4’s services were initiated. The license holder informed DHS licensors that they previously set up P4’s medications and no longer assist with medication set up. The license holder did not maintain a medication administration record for P4 for the time period when the license holder was setting up P4’s medications, that documented the following: · dates of set up; · name of medication; · quantity of dose; · times to be administered; and · route of administration at time of set up. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1 and 1a. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not provide services in response to the person’s identified needs and in compliance with the federal waiver plans as required. The license holder did not provide the following integrated community support services as assigned in P1, P2 and P4’s support plan. The provision of services did not comply with the requirements of this chapter and the federal waiver plans: · the license holder maintained information in P1’s record that documented P1 was to receive eight hours of in person support and two hours of remote support per day. The license holder maintained timesheets for P1’s direct support staff that consistently documented less hours than what the license holder was assigned to provide according to P1’s support plan; · the license holder maintained information in P2’s record that documented P2 was to receive ten hours of in person support and two hours of remote support per day. The license holder maintained timesheets for P2’s direct support staff that consistently documented less hours than what the license holder was assigned to provide according to P2’s support plan; and · the license holder maintained information in P4’s record that documented P4 was to receive ten hours of in person support and two hours of remote support per day. The license holder maintained timesheets for P4’s direct support staff that consistently documented less hours than what the license holder was assigned to provide according to P4’s support plan. Corrective Action Ordered: Immediately, upon receiving this order, you must comply with the requirements of this chapter and the federal waiver plans. Within 30 days or receiving this order, you must meet with P4, P4’s case manager, and other members of the support team to evaluate the in person and remote hours needed to support P4 in the community living service categories. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, Section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not complete assessments and initial service planning as required. a. The license holder did not complete a preliminary support plan addendum for P1 and P4 based on the support plan within 15 working days of service initiation. The license holder initiated P1’s services on February 1, 2025, and completed a preliminary support plan for P1 on May 13, 2025. The license holder initiated P4’s services on April 1, 2025, and completed a preliminary support plan for P4 on August 7, 2025. b. The license holder did not complete assessments for P1, P2, and P4 before providing 45 days of service. The license holder initiated P1’s services on February 1, 2025, and completed P1’s assessments on May 13, 2025. The license holder initiated P2’s services on September 1, 2023, and completed P2’s assessments on October 27, 2023. The license holder initiated P4’s services on April 1, 2025, and completed P4’s assessments on August 4, 2025. c. The license holder did not conduct assessments for P2 annually in 2024 and 2025. d. The license holder did not ensure P4’s assessments produced information about the person that described P4’s overall strengths, functional skills and abilities, and behaviors of symptoms. e. The license holder did not hold an initial service planning meeting with P1, P1’s case manager, P2 and P2’s case manager, P4 and P4’s case manager, and other members of the support team or expanded support team before providing 45 days of service to determine the following: · 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; · 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; and · a discussion of how technology might be used to meet the person's desired outcomes, including a summary of this discussion, a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. The license holder initiated P1’s services on February 1, 2025, and held an initial service planning meeting on May 13, 2025. The license holder initiated P2’s services on September 1, 2023, and held an initial service planning meeting on October 27, 2023. The license holder initiated P4’s services on April 1, 2025, and held an initial service planning meeting on August 6, 2025. Corrective Action Ordered: Within 30 days or receiving this order, you must: · complete P2’s assessment and review the assessment with P2, P2’s case manager and other members of the support team. You must document the date the assessment was reviewed; and · revise P4’s assessments to ensure the assessments produce information about P4 that describes the P4's overall strengths, functional skills and abilities, and behaviors or symptoms. Compliance with this order will be monitored onsite. On an ongoing basis you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not develop service outcomes and supports as required. a. The license holder did not develop a service plan for P1, P2, and P4 that documented the service outcomes and supports that included the following supports and methods to be implemented to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being within 10 working days of the initial planning meeting: · the methods or actions that would be used to support the person and accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment and materials required; and o techniques that were consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods. b. The license holder completed service outcomes and supports for P2 this on October 27, 2023. The license holder did not submit to and obtain dated signatures from P2’s case manager to document completion and approval of the assessment and support plan addendum within 20 working days of the 45-day meeting. The license holder completed this on December 23, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P1 and P1’s case manager, P4 and P4’s case manager, and their support teams to determine the supports and methods to be implemented to support the person and accomplish their outcomes; · within 10 working days of this meeting, develop a service plan for P1 and P4 that documents the service outcomes and supports and included the supports and methods identified above. You must maintain documentation of the service outcomes and supports in P1’s and P4’s support plan addendum; · within 20 working days of this meeting, submit and obtain dated signatures from P1 and P1’s case manager and P4 and P4’s case manager to document completion and approval of the support plan addendum; · audit all service recipient records receiving intensive support services to ensure the supports and methods identified above are documented in the person’s support plan addendum; · for any service recipient in which the supports and methods identified above are not documented in the person’s support plan addendum, develop a service plan that documents the supports and methods and maintain this service plan in the person’s support plan addendum; · provide training to all direct support staff that provide direct support services to P1 and P4 on P1’s and P4’s service outcomes and supports; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P2), the license holder did not meet requirements for service plan review and evaluation. a. The license holder did not participate in an annual service plan review meeting with P2 and P2’s case manager following stated timelines in P2’s support plan addendum in October 2025. The license holder completed the service plan review meeting in December 2025. b. The license holder did not give P2’s case manager an opportunity to participate in service plan review meetings following stated timelines established in the person’s support plan or support plan addendum in 2023, 2024 and 2025. c. The license holder did not send P2’s support plan addendum to P2’s case manager within ten working days of the progress review meeting in October 2023 and October 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain service recipient records as required. The license holder did not maintain progress or daily log notes that are recorded by the program in P1 through P4’s service recipient records.
Corrective Action Ordered: Immediately, upon receiving this order, you must maintain progress or daily log notes for all service recipients. Compliance this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2, and P4) the license holder did not inform and provide policies and procedures to the case manager as required. a. The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights to P1 and P1’s case manager, P4 and P4’s case manager within five working days of intensive support service initiation. The license holder initiated P4’s services on April 1, 2025 and provided these policies to P4 and P4’s case manager on August 6, 2025 : · grievance policy and procedure; · service suspension policy and procedure; · service termination policy and procedure; and · data privacy requirements. b. The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P2’s case manager within five working days of intensive support service initiation on September 1, 2023. The license holder provided these policies to P2’s case manager in January 2024.: · grievance policy and procedure; · service suspension policy and procedure; · service termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy requirements. c. The license holder did not inform and provide a copy of the license holders policy on the emergency use of manual restraint to P1 and P4’s case manager within five working days of service initiation. The license holder provided this policy to P4’s case manager on August 4, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the policies and procedures identified above to P1 and P1’s case manager; and · maintain documentation at your program for review by DHS licensors. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2, and P4), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate with P1, P2, and P4 whether the identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate P1’s, P2’s and P4’s identified positive support strategies. 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. On an ongoing basis, you must maintain compliance as required in this subdivision. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subpart. 13. Citation: Minnesota Rule 9544.0080, subpart 1. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not provide notice of the emergency use of manual restraint policy as required. The license holder did provide notice and obtain written acknowledgement from P1 and P4 of the license holders policy on the emergency use of manual restraint at the time of service initiation. The license holder initiated P4’s services on April 1, 2025. The license holder provided notice and obtained written acknowledgement of this policy on August 6, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with notice and obtain written acknowledgment of the emergency use of manual restrain policy. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subpart. 14. Citation: Minnesota Statutes, section 245A.041, subdivision 4: Violation: For three persons whose records were reviewed (P1, P2, and P4) the license holder did not meet the requirements for electronic record keeping as required. The license holder did not ensure that the use of electronic record keeping did not limit the commissioner’s access to records as specified under section 245A.04, subdivision 5. Corrective Action Ordered: Immediately, upon receiving this order, you must ensure that the use of electronic record keeping does not limit the commissioner’s access to records as specified under section 245A.04, subdivision 5. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subpart. 16. Citation: Minnesota Statutes, Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to maltreatment reporting as required. a. The license holder did not provide SP1 and SP2 with orientation on vulnerable adult maltreatment reporting including a review of all the license holder’s internal policies and procedures related to prevention and reporting of maltreatment of individuals receiving services. SP1 was hired on February 14, 2025. The license holder provided this orientation on December 11, 2025. SP2 was hired on October 21, 2024. The license holder provided this orientation on December 16, 2025. b. The license holder did not provide SP1 and SP2 with orientation to the license holder’s program abuse prevention plan within 72 hours of first providing direct contact services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 and SP2 with the orientation to the program abuse prevention plan; · maintain documentation in SP1 and SP2’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation to maltreatment reporting was provided; · for the direct support staff that did not have orientation training requirements met, you must provide the orientation; and · maintain documentation with your audit findings. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. The license holder did not provide the following orientation to SP1 within 60 calendar days of hire on February 14, 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 license holder provided SP1 with this training on December 11, 2025; · 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 license holder provided SP1 with this training on December 11, 2025; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. The license holder provided SP1 with this training on December 11, 2025; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. The license holder provided SP1 with this training on December 11, 2025; · 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. The license holder provided SP1 with this training on December 11, 2025; · 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 provided SP1 with this training on December 11, 2025. b. The license holder did not provide the following orientation to SP2 within 60 calendar days of hire on October 21, 2024: · the job description and how to complete specific job functions, including responding to and reporting incidents, and following safety practices established by the license holder and as required. The license holder provided this training on December 16, 2025; · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures; · 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 license holder provided SP2 with this training on December 16, 2025; · 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 license holder provided SP2 with this training on December 16, 2025; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. The license holder provided SP2 with this training on December 16, 2025; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. The license holder provided SP2 with this training on December 16, 2025; · 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. The license holder provided SP2 with this training on December 16, 2025; · 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 provided SP2 with this training on December 16, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 with orientation training on basic first aid; · provide SP2 with the orientation training on the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures and basic first aid; · maintain documentation in SP1 and SP2’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation training was provided; · for the direct support staff that did not have orientation training requirements met, you must provide the orientation; and · maintain documentation with your audit findings. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. 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 individual service recipient needs as required. a. The license holder did not provide SP1 and SP2 with orientation to individual needs before having unsupervised direct contact with a person served, including the person's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. b. The license holder did not provide SP1 with orientation training on medication set up from a training curriculum developed by a registered nurse or appropriate health professional and incorporated an observed skill assessment conducted by the trainer to ensure SP1 demonstrated the ability to safely and correctly follow medication procedures prior to SP1 performing medication set up. The license holder informed DHS licensor’s that SP1 is no longer providing medication set up to P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 and SP2 with orientation to individual service recipient needs documented above for any person they provide direct contact to; · maintain documentation in SP1 and SP2’s record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor; · audit all personnel records to determine if orientation to individual service recipient needs was provided; · for the direct support staff that did not have orientation to individual service recipient needs, you must provide the orientation; and · maintain documentation with your audit findings. Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.095, subdivision 5: Violation: For two staff persons whose records were reviewed (SP1) the license holder did not maintain personnel record as required. The license holder did not maintain documentation in SP1’s personnel record that included the number of hours per subject area and the name of the trainer or instructor. Corrective Action Ordered: Compliance with this order will be maintained on site. On an ongoing basis, you must maintain compliance as required in this subpart. 20. Citation: Minnesota Statutes, section 245D.081, subdivision 2 and 3. Violation: For one staff person (SP4), the license holder did not meet the requirements of program coordination, evaluation and oversight. a. The license holder did not ensure the designated coordinator (SP4), provided supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the persons support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder did not ensure that the designated manager (SP4) provided program management and oversight of the services provided by the license holder that include: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph e, and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in section 245D.07 and 245D.071 and ensuring and protecting each person’s rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations 1 through 19 for the designated coordinator and designated manager’s failures to provide the above stated requirements. Corrective Action Ordered: Within 30 days of receiving this order, you must designate a staff person who is responsible for delivery and evaluation of services provided by the license holder. You must also designate a managerial staff person to provide program management and oversight of the services provided by the license holder. The same person may perform both functions if the work and education requirements are met in section 245D.081, subdivisions 2 and 3. You must submit the name(s) and qualifications of the staff person or staff persons who will act as the designated coordinator and designated manager to your licensor. 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 kelly.bosch@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: Kelly Bosch 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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