|
March 13, 2026 Hussein Warsame, Authorized Agent Comfort Home Health Services LLC 4141 Central Avenue Northeast STE 120N Columbia Heights, Minnesota 55421 License Number: 1097090 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Hussein Warsame: On January 20, 2026, a licensing review of Comfort Home Health Services LLC, located at 4141 Central Avenue Northeast STE 120N, Columbia Heights, Minnesota was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one of four persons whose records were reviewed (P4), the license holder did not provide an orientation to the maltreatment reporting procedures as required. The license holder initiated P4’s services July 16, 2024. The license holder did not provide P4 with an orientation to the internal and external reporting procedures of suspected or alleged maltreatment within 24 hours of admission. The license holder provided P4 with the orientation on September 18, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two persons whose record were reviewed (P3 and P4), the license holder did not meet the requirements for an abuse prevention plan as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year.
a. The license holder did not review P3’s individual abuse prevention plan (IAPP) annually in 2025. The license holder reviewed P3’s IAPP on November 14, 2024, and on January 16, 2026. b. The license holder did not provide P4 with an orientation to the program abuse prevention plan (PAPP) within 24 hours of admission. c. The license holder initiated P4’s services on July 23, 2024. The license holder did not develop an IAPP as part of the initial individual program plan or service plan prior to or upon service initiation. The license holder developed an IAPP for P4 on September 18, 2024. Additionally, the license holder assessed P4 as susceptible to sexual abuse and financial exploitation. The license holder did not document the specific actions the program would take to minimize the risk of abuse to P4 within the scope of services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P4 with an orientation to the PAPP, and maintain documentation of this orientation in P4’s service recipient record; · revise P4’s IAPP to include statements of the specific actions the program would take to minimize the risk of abuse to P4 in all areas of assessed abuse within the scope of the licensed service; · provide P4’s case manager with an opportunity to review P4’s revised IAPP; and · obtain written acknowledgement of this review from P4’s case manager. You must maintain this documentation in P4’s service recipient record. 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 a written notice that identified the service recipient rights, 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 P1 or P1’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights annually in 2024. b. The license holder did not provide P2 and P2’s legal representative with a notice that identified the right to access to the person’s personal possessions, including financial resources, in the notice that was provided to P2 and P2’s legal representative on July 1, 2025. c. The license holder initiated P4’s services on July 16, 2024, and provided P4 with a written notice that identified the service recipient rights and an explanation of those rights. The license holder provided P4 with this notice on September 9, 2025. The license holder did not provide P4 with an annual written notice that identified the service recipient rights and an explanation of those rights in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2 with a written notice of the service recipient rights that includes the above-mentioned right. You must maintain documentation of P2’s legal representative’s receipt of a copy and an explanation of the rights. You must maintain this receipt of acknowledgement in P2’s service recipient record. 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 document health needs as required. The license holder did not maintain documentation on how P4’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication setup, assistance or administration according to this chapter; and · assist with or coordinate medical, dental, and other health service appointments. Corrective Action Ordered: Within 30 days of receiving this order, you must document how P4’s health needs will be met as outlined above. You must provide training to all staff that work with P4 on the updated information about how P4’s health needs will be met. You must maintain documentation of this training in staff persons’ personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not comply with the requirements of this subdivision. The Community-Based Services Manual (CBSM) page titled “individualized home supports” defines individualized home supports with family training as a service that provides support and training to the person and/or their family. The CBSM states the training provided as part of the service is to increase their capabilities to care for and maintain the person’s ability to live in the home. The license holder provided individualized home supports with family training services to P1. The license holder did not maintain documentation within P1’s support plan addendum that indicated what supports and training the license holder was providing to P1 and/or P1’s family as part of this service. Corrective Action Ordered: Immediately upon receiving this order, you must provide services to P1 that comply with the requirements of this chapter and the federal waiver plan. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (d). Violation: For one person whose record was reviewed (P3), the license holder did not meet service plan review requirements for a basic support service. The license holder assigned themselves the responsibility of annual service planning and support team meetings in P3’s support plan addendum. The license holder did not participate in annual meetings for P3 in 2023, 2024 and 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P3, P3’s legal representative, case manager, and members of the support team as assigned in P3’s support plan addendum. You must document the date of the meeting, who attended the meeting, and what was discussed and determined at the meeting in P3’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not provide written reports as required in this subdivision. The license holder documented in P1’s support plan addendum that progress reports and recommendations would be sent annually to P1’s case manager. The license holder completed P1’s most recent progress report and recommendations on June 13, 2025. The license holder did not provide P1’s case manager with this report until January 6, 2026. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b), (c), and (d). Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not meet initial service planning and assessment requirements for an intensive support service. The license holder did not meet with P2, P2’s legal representative, P2’s case manager, and members of P2’s support team, and with P4 and P4’s case manager, and members of P4’s support team within 45 days of service initiation to determine: · 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; · 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; · a discussion of how technology might be used to meet the person's desired outcomes. The 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P2, P2’s legal representative, and members of P2’s support team, and with P4 and P4’s case managers and members of P4’s support teams to determine the above mentioned items and to have a discussion about how technology might be used to meet the person’s desired outcomes. You must include a summary of this discussion in P2’s and P4’s support plans or support plan addendums; · review the results of P2’s and P4’s assessments with P2, P2’s legal representative, and members of P2’s support team, and with P4, P4’s case manager, and members of P4’s support team. You must maintain documentation of this review in P2’s and P4’s service recipient records; · provide training to all staff that work with P2 and P4 on the updated support plan addendums; and · maintain documentation of this training in staff persons’ personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not meet the requirements for services outcomes and supports. The license holder did not develop service plans for P2 and P4 that documented the service outcomes and supports to accomplish outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan for P2 and P4 that documents the service outcomes and supports that includes the following: o 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; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o 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 o the names of the staff or position responsible for implementing the supports and methods; · provide training to all staff that work with P4 on the updated support plan addendums; and · maintain documentation of this training in staff persons’ personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not meet service plan review and evaluation requirements. a. The license holder did not meet with P1’s case manager to participate in service plan review meetings at least once per year to determine whether changes were needed to the service plan based on: · the assessment information; · the license holder’s evaluation of progress toward accomplishing outcomes; or · other information provided by the support team or expanded support team. Additionally, the license holder did not meet with P1, P1’s legal representative, and P1’s case manager at least once per year to discuss how technology might be used to meet the person’s desired outcomes. b. The license holder did not give P4’s case manager an opportunity to participate in the ongoing review and development of the service plan for P4 and the methods used to support P4 and accomplish outcomes in 2025. The license holder held a service plan review meeting with P4 and other people as identified by P4. The license holder did not notify P4’s case manager of this meeting or invited to attend. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P1, P1’s legal representative, and P1’s case manager to participate in a service plan review to determine if changes are needed to the service plan based on the above-mentioned information; · discuss how technology might be used to meet P1’s desired outcomes and document a summary of this discussion in P1’s support plan addendum; · include a description of any further research that must be completed before a decision regarding the use of technology can be made in the person’s support plan addendum; and · ensure P4’s case manager is included in all service plan review meetings. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P4), the license holder did not provide written or electronic copies of policies and procedures that affect a persons rights, as required. The license holder did not inform P4 and case manager of the policies and procedures that affect a person’s rights within five working days of service initiation. The license holder initiated P4’s services on July 16, 2024, and provided the policies and procedures on September 18, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation in the service recipient record, as required. a. The license holder did not maintain a signed statement authorizing the license holder to act in a medical emergency when P1’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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain a signed statement from P1’s legal representative authorizing the license holder to act in a medical emergency when P1’s legal representative cannot be reached or is delayed in arriving; and · start maintaining progress or daily log notes in P1’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Rule, part 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not incorporate and evaluate the positive support strategies as required. a. The license holder did not incorporate in writing positive support strategies to an existing treatment, service, or other individual plan for P1 and P4. b. The license holder did not evaluate the identified positive support strategies at least every six months with P2. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and document positive support strategies for P1 and P4; · evaluate the positive support strategies with P2; and · maintain documentation of this evaluation in P2’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subpart. 14. 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 emergency use of manual restraints policy, as required. The license holder initiated P4’s services on July 16, 2024. The license holder provided P4 with a notice of the license holder’s emergency use of manual restraints policy and procedure on September 18, 2024. The license holder did not provide P4 with a notice of the license holder’s emergency use of manual restraints policy and procedure at the time of service initiation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of five staff persons whose records were reviewed (SP4), the license holder did not provide orientation to the PAPP as required. SP4’s date of hire was January 8, 2025. The license holder did not provide SP4 with an orientation to the PAPP within 72 hours of first providing direct contact services to a vulnerable adult. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP4 with an orientation to the PAPP. You must maintain documentation of this orientation in SP4’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For three staff persons whose records were reviewed (SP1, SP2 and SP4), the license holder did not provide orientation training as required. a. The license holder did not provide SP1 with the following orientation training: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder before SP1 had unsupervised direct contact with a person served by the program; · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under Minnesota Statutes, section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · 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 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. b. The license holder did not provide SP2 and SP4 with orientation in the following areas within 60 calendar days of hire: · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1, SP2 and SP4 with training on the above-mentioned training topics. You must maintain documentation of this training in SP1’s, SP2’s and SP4’s personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and 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 with annual training on the following topics in 2024 and 2025: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; which includes: o review to vulnerable adult maltreatment reporting; o review to maltreatment to minors reporting (if applicable); and o review to the license holder’s program abuse prevention plan; · 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 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 restraints; · 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. The license holder did not provide SP3 with annual training on the following topics in 2023, 2024 and 2025: · data privacy requirements according to Minnesota Statutes, sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; which includes: o review to vulnerable adult maltreatment reporting was received; o review to maltreatment to minors reporting (if applicable); and o review to the license holder’s program abuse prevention plan; · 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 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 restraints; · 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; 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 and SP3 with the above-mentioned training. You must maintain documentation of this training in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For one person whose record was reviewed (SP1), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP1 that included the following information: · the date of SP1’s first supervised direct contact with a person served by the program; and · the date of SP1’s first unsupervised direct contact with a person served by the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services 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. Kate Spenger, HCBS Licensor Licensing Division Office of Inspector General 651-431-5757
|
