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March 3, 2026 Elizabeth McGraw Spike, Authorized Agent AME Community Services Inc 151 5th Street Northeast Suite 104 Buffalo, Minnesota 55313 License Number: 1068370 (245D – HCBS) CORRECTION ORDER Dear Elizabeth McGraw Spike: On February 3-4, 2026, a licensing review of AME Community Services Inc, located at 151 5th Street Northeast Suite 104, Buffalo, 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 review an individual abuse prevention plan (IAPP) 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. The license holder did not review P4’s IAPP with P4’s support team annually in 2025. The license holder reviewed P4’s IAPP in February 2024 and September 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision.
2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not provide service recipient rights as required. a. The license holder did not provide P1 or P1’s legal representative with a written notice that identified the service recipient rights, and explanation of those rights within five working days of service initiation. The license holder initiated P1’s respite support services on May 16, 2025, and provide these rights to P1 and P1’s legal representative on January 30, 2026. b. The license holder did not provide P4 and P4’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. The license holder provided P4 and P4’s legal representative with this written notice in February 2024 and October 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not document how health needs would be met. a. The license holder was responsible for meeting P2’s health needs. The license holder did not maintain documentation on how P2’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication administration; · monitor health conditions according to written instructions from a licensed health professional; and · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a license health professional.
a. The license holder was assigned the responsibility of medication administration for P4, which included a psychotropic medication to be administered as needed (PRN). The license holder did not document a description of the procedures the license holder would follow in order to administer this medication. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document how you will meet P2’s health needs, including the above information, in P2’s support plan addendum; and · document a description of the procedures you will follow when administering P4’s PRN medication. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not provide medication administration as required. a. The license holder was responsible for meeting P2’s health needs including the administration of multiple scheduled and as needed treatments. The license holder did not ensure the following information was documented in P2’s medication administration record to ensure P2 received treatments as prescribed: · 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 treatment to be provided, and the frequency and other information needed to safely and correctly administer the treatment to ensure effectiveness; · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use; and · the possible consequences if the medication or treatment is not taken or administered as directed. b. The license holder was assigned the responsibility for medication administration for P4. The license holder did not notate each 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 of the person, and when and to whom the report of the occurrence was made. On numerous dates throughout 2024 and 2025, the medication administration records for P4 showed medications that were not signed as administered with no additional documentation on whether the medication was missed, refused, or if it was a documentation error and no documentation to show that these occurrences were reported to P4’s legal representative and case manager. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document the above information in P2’s medication administration record; and · audit P4’s MARs for 2025 through present. You must document and notify P4’s legal representative and P4’s case manager of each occurrence in which P4 did not receive a medication or treatment as prescribed. You must maintain documentation that this notification occurred. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a). Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not review and report medication administration issues as required. a. The license holder was assigned responsibility for medication assistance in P3’s support plan and support plan addendum. The license holder did not report the following to P3’s legal representative and case manager: · any reports required under subdivision 2, paragraph (c), clause (4); · P3’s refusal or failure to take or receive medication or treatment as prescribed; and · concerns about P3’s self-administration of medication or treatment. b. The license holder did not complete medication administration record (MAR) reviews for P4 at a minimum of every three months to identify medication errors, including documentation errors, in 2023, 2024, and 2025. Based on the results of the review, the license holder was to develop and implement a plan to correct patterns of medication errors when identified. The license holder maintained a document indicating that MAR reviews were completed for P4 in 2023, 2024, and March and May of 2025. However, each documented review stated that there were no medication errors and the review did not identify a need to develop and implement a plan to correct patters of errors. This was not consistent with the MARs for the corresponding months, which showed numerous occurrences of medications not being administered as prescribed. Corrective Action Ordered: Within 30 days of receiving this order, you must complete medication administration record reviews for January 2025 through current. You must identify any medication errors, including documentation errors. Based on the results of the review, you must develop and implement a plan to correct patterns of errors. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P4), the license holder did not meet the conditions for administering psychotropic medications as required. The license holder administered medication to P4, including psychotropic medications. The license holder did not maintain a description of the target symptoms that each psychotropic medication was to alleviate in the person’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must document the target symptoms for P4 that each of P4’s psychotropic medications are to alleviate. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not comply with the provision of services as required. According to the Community-Based Services Manual, individualized home supports with family training cannot be provided by a relative. The license holder provided P2 with individualized home supports with family training services. The license holder did not comply with the federal waiver plan when P2’s legal representative was hired by the license holder as a staff person to provide individualized home supports with family training to P2. Corrective Action Ordered: Immediately, upon receiving this order, you must comply with the provision of services according to the requirements of this chapter and the federal waiver plans. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for basic support services as required. The license holder did not review and revise P1’s preliminary support plan addendum to document the service that would be provided including how, when, and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services within 60 days of initiating P1’s respite support services. The license holder initiated P1’s respite support services on May 16, 2025, and revised P1’s support plan addendum to include the information documented above on January 30, 2026. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P4), the license holder did not complete assessments as required. The license holder did not complete the required assessments for P4 annually in 2025. The license holder completed the required assessments for P4 in February 2024 and September 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not develop service outcomes and supports as required. a. The license holder did not document the supports and methods to be implemented to support P2 in accomplishing their desired outcome, including: · methods or actions that would 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; · 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 document the supports of methods to be implemented to support P3 in accomplishing their desired outcome, including: · any changes or modification to the physical and social environments necessary when the service supports are provided; and · techniques that were consistent with the P3's communication mode and learning style. Corrective Action Ordered: Within 30 days of receiving this order, you must document and implement the supports and methods identified above for P2 and P3 and maintain this documentation in the person’s support plan addendum. On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b). Violation: For three persons whose records were reviewed (P3, P4, and P5), the license holder did not discuss how technology may be used to meet the person’s desired outcome as required. The license holder did not meet with P3, P4, and P5, and the person’s support team, to discuss how technology might be used to meet the person's desired outcomes in 2024 and 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P3’s, P4’s, and P5’s support team to discuss how technology might be used to meet the person’s desired outcome; and · document a summary of this discussion that includes a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g). Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not provide a progress review report as required. The license holder did not provide P3’s and P4’s support team with a progress review report in 2025 that included the following: · a summary of the person’s status and progress towards achieving the identified outcomes; · recommendations; and · the rationale for changing, continuing, or discontinuing implementation of the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P3’s and P4’s support team with a progress review report that includes the above information. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.10, subdivision 4, and Minnesota Rule, 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide written or electronic copies of policies and procedures as required. a. The license holder did not inform P1 and P1’s case manager of the policies and procedures affecting P1’s rights, and provide copies of the following policies and procedures, within 5 working days of service initiation. The license holder initiated P1’s services respite support services on May 16, 2025. • grievance policy; • temporary service suspension policy; and • service termination policy; b. The license holder did not provide P1 and P1’s legal representative with notice of the license holders policy on the emergency use of manual restraint and obtain written acknowledgement from P1’s legal representative when P1’s respite support services were initiated on May 16, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 and P1’s case manager with the above-mentioned policies and procedures; and · provide P1 and P1’s legal representative with notice of the license holders policy on the emergency use of manual restraint and obtain written acknowledgement from P1’s legal representative. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 14. Citation: Minnesota Rules, part 9544.0100, subpart 3. Violation: For one person whose record was reviewed (P3), the license holder did not maintain documentation of outcomes as required. The license holder did not document the progress or lack of progress towards achieving each outcome or goal for P3. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivisions 4 and 4a. Violation: For three of seven staff persons whose records were reviewed (SP1, SP2, and SP5), the license holder did not provide orientation training as required. a. The license holder did not provide SP1, SP2, and SP5 with an orientation to strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities, within 60 days of hire. b. SP5 provided direct support services to a person served by the program who required medications to be administered through a specific route. The license holder did not ensure SP5 reviewed and received instruction on medication administration procedures established for the person. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1, SP2, and SP5 an orientation to strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; · ensure SP5 reviews and receives instruction on medication administration procedures established for the person they provide direct support services to; and · maintain documentation of these trainings in SP1’s, SP2’s, and SP5’s personnel records as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For four staff persons whose records were reviewed (SP1 through SP4), 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: · 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 this training in September 2024 and December 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 this training in September 2024 and December 2025; · 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; the license holder provided this training in October 2024 and December 2025; · the program abuse prevention plan; the license holder did not provide this training in 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 this training in September 2024 and December 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 this training in October 2024 and December 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 this training in October 2024 and December 2025; and · basic first aid; the license holder provided this training in September 2024 and December 2025. b. The license holder did not provide SP2 with annual training on the program abuse prevention plan in 2025. c. The license holder did not provide SP3 with annual training on the following topics in 2023, 2024, and 2025: · the program abuse prevention plan; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. d. The license holder did not provide SP4 with annual training on the following topics: · 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 this training in May 2023 and June 2024; · 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; the license holder provided this training in May 2023 and June 2024; · the program abuse prevention plan; the license holder did not provide this training in 2023, 2024, and 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 this training in May 2023 and June 2024; · 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 this training in March 2024 and April 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 this training in March 2024 and April 2025; · basic first aid; the license holder provided this training in March 2024 and April 2025; 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 did not provide this training in 2023, 2024, and 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 through SP4 training on the program abuse prevention plan(s) for any site CRS location at which SP1 through SP4 provide direct support services; · provide SP3 and SP4 training on strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · maintain documentation of these trainings in SP1’s through SP4’s personnel records as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP5), the license holder did not maintain personnel records as required. The license holder did not maintain personnel records for SP1, SP2, and SP5 that documented orientation and training that included the number of hours per subject area. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Tiffany Solano, HCBS Licensor Licensing Division Office of Inspector General 651-431-6649
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