Minnesota

April 17, 2026

Inas Muhidine, Authorized Agent

Royalty Health Care Inc

941 Hillwind Road Northeast Suite 100-C

Fridley, Minnesota 55432

License Number: 1103752 (245D – Home and Community-Based Services)

CORRECTION ORDER

Dear Inas Muhidine:

On February 10, 2026, a licensing review of Royalty Health Care Inc, located at 941 Hillwind Road Northeast Suite 100-C Fridley, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: For one of five persons whose record was reviewed (P4), the license holder did not develop an individual abuse prevention plan (IAPP) as required.

The license holder did not develop an IAPP that contained an accurate individualized assessment of the following for P4:

· the person's susceptibility to abuse by other individuals, including other vulnerable adults; and

· the person's risk of abusing other vulnerable adults.

The IAPP the license holder developed for P4 in 2025 indicated that P4 was not susceptible to abuse in any area. This assessment was not consistent with information maintained elsewhere in P4’s record.

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

· review and revise P4’s IAPP to include accurate assessments of the above-mentioned information; and

· include statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults.

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

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

Violation: For three persons whose records were reviewed (P3, P4 and P5), the license holder did not provide a written notice that identified the service recipient rights and an explanation of those 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 a P5 or P5’s legal representative with a written notice of service recipient rights and an explanation of those rights annually in 2025 for P5’s individualized home supports with training services. Additionally, the license holder did not provide P5 or P5's legal representative with a written notice of service recipient rights within 5 days of service initiation for P5’s individualized home supports with family training services on November 2, 2024. The license holder provided the written notice to P5 and P5's legal representative on November 1, 2025.

b. The license holder did not provide P4 with a written notice that identifies the service recipient rights and an explanation of those rights annually in 2024. The license holder provided P4 with a written notice in August 2023 and in September 2025.

c. 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 within five days of service initiation. The license holder initiated a service for P3 on June 20, 2024, and an additional service on December 23, 2024. The license holder provided P3’s legal representative with a written notice on April 8, 2025.

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

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

Violation: For one person whose record was reviewed (P2), the license holder did not document health needs as required.

During the review, the license holder stated that they assist with transfers from P2’s wheelchair to P2’s bed with the assistance of a transfer belt and sliding board. The license holder did not maintain documentation on how P2’s health needs would be met, including the use of medical equipment, devices, or adaptive aides safely and correctly according to written instructions from a licensed health professional.

Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s support plan addendum to maintain the above documentation. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.05, subdivisions 1b and 2.

Violation: For one person whose record was reviewed (P3), the license holder did not provide health services as required.

The license holder was assigned responsibility in P3’s support plan addendum to provide P3 with medication assistance and to administer P3’s psychotropic medications. The license holder did not:

· implement medication administration procedures to ensure P3 takes medications and treatments as prescribed;

· obtain written authorization from P3 or P3’s legal representative to administer medication or treatment; and

· ensure the following information was documented in P3’s medication administration record (MAR):

o the information on the current prescription label or the prescriber's current written or electronically recorded order or prescription that includes the person's name, description of the medication or treatment to be provided, and the frequency and other information needed to safely and correctly administer the medication or treatment to ensure effectiveness;

o information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information must be readily available to all staff administering the medication;

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

o instruction on when and to whom to report the following:

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

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

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

o notation of when a medication or treatment is started, administered, changed, or discontinued.

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

· obtain written authorization from P3 or P3’s legal representative to administer medication or treatment;

· implement medication administration procedures to ensure P3 takes medications and treatments as prescribed;

· ensure the information identified above is documented in P3’s MAR;

· ensure P3’s staff have completed training according to section 245D.09, subdivision 4a, paragraph (d);

· provide P3’s staff with review and instruction on P3’s updated support plan addendum; and

· maintain documentation of the staff training according to Minnesota Statutes 245D.095.

Compliance with this order will be reviewed onsite 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.07, subdivision 1.

Violation: For one person whose record was reviewed (P5), 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 P5. The license holder did not maintain documentation in P5’s support plan addendum that indicated what supports and training the license holder was providing to P5 or P5’s family as part of this service.

Corrective Action Ordered: Immediately upon receiving this order, you must:

· provide services to P5 according to the requirements in the federal waiver plan; and

· meet with P5, P5’s legal representative, and P5’s case manager to ensure your service delivery planning for P5 complies with the requirements of the federal waiver plan. You must document this meeting, including what was determined at the meeting, and maintain this documentation in P5’s service recipient record.

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

6. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For one person whose record was reviewed (P2), the license holder did not provide services in response to P2’s identified needs and in compliance with the federal waiver plans as required.

The license holder did not provide services in response to P2’s identified needs as specified in P2’s support plan, and in compliance with the requirements of this chapter. The license holder provided night supervision to P2. The license holder did not document in P2’s 2025 support plan addendum how the license holder was providing night supervision to P2 in response to P2’s identified needs, interests, preferences and desired outcomes.

Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s support plan addendum to accurately reflect the services being provided by the license holder and how the services will be provided in response to P2’s needs, interests, preferences, and desired outcomes. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.07, subdivision 2 and subdivision 3.

Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning requirements for basic support services.

The license holder was assigned the responsibility to participate in annual service planning and support team meetings and to provide annual written reports for P2. The license holder did not participate in service planning and support team meetings or provide written reports for P2 annually in 2023, 2024, or 2025.

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

· hold a service planning and support team meeting with P2, P2’s case manager’s and members of P2’s support team;

· provide a written report regarding P2’s progress or status to P2’s case manager and members of the support team;

· maintain documentation of the support team meeting, including what was discussed, the date of the meeting and who attended the meeting, and a copy of the written report you provided in P2’s service recipient record.

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

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

Violation: For two persons whose record were reviewed (P3 and P5), the license holder did not provide service planning and delivery for intensive support services as required.

The license holder did not complete assessments for P3 and P5 to produce information about the person that described the person’s overall strengths, functional skills and abilities, and behaviors or symptoms in the following areas within 60 days of initiating P3’s and P5’s intensive support services:

· the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments;

· the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and

· the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others.

Additionally, the license holder did not complete the assessments above for P5 on an annual basis in 2025.

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

· complete P3’s and P5’s assessments in the areas identified above that produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms;

· review the assessments with P3’s support team, and with P5’s support team, as part of a service plan review

· maintain documentation of support team review of the assessments in P3’s and P5’s service recipient records;

· train P3’s and P5’s staff persons on the person’s updated support plan addendum; and

· maintain documentation according to Minnesota Statutes 245D.095.

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

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

Violation: For one person whose record was reviewed (P5), the license holder did not meet initial service planning requirements for an intensive support service.

The license holder did not have a discussion how technology may be used to assist P5 with achieving their desired outcomes at the initial service planning meeting the license holder held on December 10, 2024.

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

· discuss with P5, their case manager, their legal representative, and members of the support team about how technology might be used to meet P5’s desired outcomes;

· include a statement in the summary 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; and

· include a summary of this discussion in P5’s support plan or support plan addendum.

Compliance with this order will be reviewed onsite 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.071, subdivision 4.

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

a. The license holder did not develop a service plan for P3 that documented the supports and methods to be implemented to support P3 to accomplish outcomes, including the following information:

· 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;

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

· the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and

· the names of the staff or position responsible for implementing the supports and methods.

b. The license holder did not develop a service plan for P5 that documented the supports and methods to be implemented to support P5 to accomplish outcomes, including the following information:

· the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about:

o any changes or modifications to the physical and social environments necessary when the service supports are provided;

o any equipment and materials required; and

o techniques that are consistent with the person’s communication mode and learning style;

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

· the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and

· the names of the staff or position responsible for implementing the supports and methods.

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

· update P3’s and P5’s service plans to include the information identified above;

· submit to and obtain dated signatures from the P3 or P3's legal representative and case manager to document completion and approval of the support plan addendum;

· train P3’s and P5’s staff persons on the person’s updated support plan addendums and how to implement the supports and methods to support the person to accomplish outcomes; and

· maintain documentation of staff training according to Minnesota Statutes 245D.095.

Compliance with this order will be reviewed onsite 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.09, subdivisions 4 and 4a.

Violation: For two of five staff persons whose records were reviewed (SP4 and SP5), the license holder did not provide orientation training as required.

a. The license holder did not provide the following orientation training to SP4 on the following topics within 60 calendar days of hire:

· a 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 license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· 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 (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 Minnesota Statutes, section 245D.04;

· 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;

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

· the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint;

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; and

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

Additionally, the license holder did not provide orientation to SP4 on 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 (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans prior to SP4 having unsupervised direct contact with a person served by the program.

b. The license holder did not provide the following orientation training to SP5 on the following topics within 60 calendar days of hire:

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

· the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint;

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; 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 SP4 and SP5 with training on the above-mentioned training topics. You must maintain documentation of this training in SP4’s and SP5’s personnel record. Compliance with this order will be reviewed onsite 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.09, subdivision 5.

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

245A.02, subdivision 2b defines "annual" or "annually" as prior to or within the same month of the subsequent calendar year.

The license holder did not provide SP1 with the following training in 2023, 2024, or 2025:

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

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

· 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. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3;

· 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;

· basic first aid; and

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

Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with the above-mentioned training. Compliance with this order will be reviewed onsite 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.095, subdivision 3.

Violation: For three persons whose record were reviewed (P1, P3 and P5), the license holder did not maintain service recipient records, as required.

a. The license holder did not maintain progress or daily log notes in P1’s or P5’s service recipient records.

b. The license holder did not maintain a signed statement authorizing the license holder to act in a medical emergency when P3’s and P5’s legal representative cannot be reached or is delayed in arriving.

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

· begin maintaining progress or daily log notes in P1’s and P5’s service recipient records;

· obtain a signed statement authorizing the license holder to act in a medical emergency when the person’s legal representative cannot be reached or is delayed in arriving; and

· maintain this signed statement in P3’s and P5’s service recipient records.

Compliance with this order will be reviewed onsite 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.095, subdivision 4.

Violation: For one person whose record was reviewed (P3), the license holder did not ensure access to service recipient records as required.

The license holder did not ensure that staff providing services to P3 had access to information in P3’s service recipient record. The license holder maintained P3’s record at the program’s office and P3’s staff did not have access to the program’s office when providing services to P3.

Corrective Action Ordered: Within 30 days of receiving this order you must ensure that P3’s staff have access to P3’s support plan addendum unless the information is not relevant to carrying out the support plan or support plan addendum. Compliance with this order will be reviewed onsite 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 5.

Violation: For two staff persons whose records were reviewed (SP4 and SP5), the license holder did not maintain personnel records as required.

a. The license holder did not maintain a personnel record for SP4 that included the following information:

· date of first supervised direct contact with a person served by the program; and

· date of first unsupervised direct contact with a person served by the program.

b. The license holder did not maintain a personnel record for SP5 that included documentation of SP5’s orientation, including:

· the date the training was completed;

· the number of hours per subject area; and

· the name of the trainer or instructor.

16. Citation: Minnesota Statutes, section 245D.10, subdivision 4, and Minnesota Rules, part 9544.0080.

Violation: For two persons whose records were reviewed (P3 and P5), the license holder did not provide copies of the policies and procedures that affect a person’s rights, as required.

a. The license holder initiated P5’s individualized home supports with family training services on November 2, 2024. The license holder did not provide P5’s legal representative with a copy of the license holder’s emergency use of manual restraint policy and procedure within five working days of service initiation. The license holder provided a copy of the emergency use of manual restraint policy and procedure on November 5, 2025. Additionally, the license holder did not provide P5’s case manager with written or electronic copies of the following policies and procedures within five working days of initiating P5’s individualized home supports with family training:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraint policy and procedure; and

· data privacy.

c. The license holder initiated a service for P3 on June 20, 2024, and an additional service on December 23, 2024. The license holder did not inform and provide P3 and P3’s case manager of the following policies and procedures affecting a person’s rights under section 245D.04 within five days of service initiation for both services the license holder initiated for P3:

· grievance policy and procedure;

· service suspension and termination policy and procedure; and

· emergency use of manual restraint policy and procedure.

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

· provide P3 and P3’s case manager with the policies and procedures listed above and maintain documentation that the policies and procedures were provided in P3’s service recipient record;

· obtain written acknowledgement from P3’s legal representative, that P3 and their legal representative, have been notified of the license holder’s policy on the emergency use of manual restraints, as required in MN Rule, part 9544.0080; and

· provide P5’s case manager with written or electronic copies of the above-mentioned policies and procedures;

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

17. Citation: Minnesota Statutes, section 245D.11, subdivision 4.

Violation: The license holder did not establish policies and procedures for service admission as required.

The license holder did not establish policies and procedures for admission and service initiation that promoted continuity of care.

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

· establish admission policies and procedures that:

o is consistent with the service-related rights identified in section 245D.04, subdivisions 2, clauses (4) to (7), and 3, clause (8);

o identifies the criteria to be applied in determining whether the license holder can develop services to meet the needs specified in the person's support plan; and

o requires that when a person or the person's legal representative requests services from the license holder, a refusal to admit the person must be based on an evaluation of the person's assessed needs and the license holder's lack of capacity to meet the needs of the person. The license holder must not refuse to admit a person based solely on the type of residential services the person is receiving, or solely on the person's severity of disability, orthopedic or neurological handicaps, sight or hearing impairments, lack of communication skills, physical disabilities, toilet habits, behavioral disorders, or past failure to make progress. Documentation of the basis for refusal must be provided to the person or the person's legal representative and case manager upon request; and

· provide all staff persons with training on the admission policies and procedures; and

· maintain documentation of staff training according to Minnesota Statutes 245D.095.

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

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

Violation: For two persons whose records were reviewed (P3 and P5), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate with P3 and P5 whether the identified positive support strategies currently met the standards in subpart 2 at least every six months.

Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate the positive support strategies with P3 and P5. You must maintain documentation of this evaluation in P3’s and P5’s service recipient records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subpart.

19.Citation: Minnesota Statutes, section 245D.081.

Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight.

a. The license holder did not ensure that the designated coordinator (SP1, provided supervision, support, and evaluation of activities that included:

· oversight of the license holder’s responsibilities assigned in the person’s 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 service 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 (SP3) provided program management and oversight of the services provided by the license holder that included:

· 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 sections 245D.07 and 245D.071, and ensuring and protecting each person’s rights as identified in section 245.04;

· 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;

· evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.

The failure to provide program coordination, management and oversight is evidenced in citations 1 through 20.

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

· ensure SPX understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and

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

Within 60 days of receiving this order, you must:

· complete an audit of all participant and personnel records to ensure all service participant and all staff person records are in compliance with the 245D licensing requirements;

· based on the results of your audit, bring all service recipient and personnel records into compliance in the areas identified as noncompliant through the audit; and

· submit the following to your licensor:

o the audit form you have developed;

o the results of the audit; and

o the date by which all participant and personnel records will be in compliance with the 245D licensing requirements. This date must be on or before July 31, 2026.

Compliance with this order will be reviewed onsite 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.11, subdivision1.

Violation: The license holder did not maintain policies and procedures related to providing intensive support services as required.

The license holder did not establish, enforce, and maintain policies and procedures required when providing intensive support services including:

· admission policy

Corrective Action Ordered: Within 30 days of receiving this order, you must provide all staff training on the above-mentioned training topics. You must maintain documentation of this training in staff persons personnel records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 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.

Amanda Spartz, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-6092

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