|
April 24, 2026 CERTIFIED MAIL Michelle O’Toole, Authorized Agent Diversified Lifestyles, Inc. 1111 6th Street Southeast Willmar, Minnesota 56201 License Number: 1069582 (245D – HCBS) Complaint Number: 202601357 ORDER OF CONDITIONAL LICENSE Dear Michelle O’Toole: The Department of Human Services (DHS) is placing your license to provide Diversified Lifestyles, Inc., 1111 6th Street Southeast, Willmar, Minnesota, on conditional status for two years, beginning April 24, 2026. This order applies to all services licensed under Chapter 245D and the service sites detailed in the “Applicability of the Conditional License” section below. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Home and Community Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE Your program was issued a conditional license on May 3, 2024. During the course of the conditional license period, your program continued to be non-compliant with the terms of that conditional license, even after corrective action was ordered. On March 3 – 5, 2026, DHS licensors conducted licensing review and licensing complaint investigation at your facility located at 1111 6th Street Southeast, Willmar, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program did not comply with the laws and rules that apply to licensed Home and Community Based Services, citing 19 violations, 17 were repeat violations. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. PROGRAM COORDINATION AND OVERSIGHT VIOLATIONS 1. Violation: The license holder did not meet the requirements for program coordination, evaluation and oversight. a. The license holder identified SP4 as the designated coordinator. The license holder did not ensure that the staff person the license holder identified as the designated coordinator (SP4) provided the supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person support plan and the support plan addendum; · taking the necessary action to facilitate the accomplishment of outcomes according to the requirements in section 245D.07; · instructions and assistance to direct support staff implementing the support plan and the service outcomes, including the failure to have an established process in which the designated coordinator determines the competency of the person that has been delegated the responsibility to directly observe the service delivery activities to assess staff competency; · 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 outcome has been achieved according to the requirements in section 245D.07. The lack of program coordination and oversight of the services provided is evidenced in citations 2 – 19. b. The license holder identified SP4 as the designated manager. The license holder did not ensure that the staff person the license holder identified as the designated manager (SP4) performed the required program management and oversight of the services provided by the license holder including: · maintaining a current understating of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, identified in in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements were met according to the requirements in section 245D.09, subdivision 3, including ensure periodic performance evaluations of direct support staff’s ability to perform the job functions based on direct observations are completed by the license holder; · ensuring corrective action was taken when ordered by the commissioner and that the terms and conditions of the license were met; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The lack of program management and oversight of the services provided is evidenced in citations 2 - 19. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a correction order issued on October 7, 2025, you were previously found in violation of this same statute. Corrective action Ordered: Within 30 days of receipt of this order, you must: · designate a staff person, other than SP4, who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP4, to provide program management and oversight of the services provided by the license holder; and · submit this staff person’s name and qualifications to your licensor for approval. The same person may perform both functions if the work and education requirements outlined in section 245D081, subdivisions 2 and 3 are met. Within 60 days of receipt of this order, you must complete all corrective action in this order. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. SERVICE RECIPIENT VIOLATIONS 2. Violation: For five of eight persons whose records were reviewed (P1, P2, P3, P7 and P8), the license holder did not develop 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. a. The license holder assessed P1 as susceptible to sexual abuse. The license holder did not include a statement of specific measures that would be taken to minimize the risk of abuse in this assessed area. b. The license holder began providing services to P2 on January 22, 2026. The license holder did not develop an IAPP for P2 prior to or upon service initiation. Furthermore, the license holder did not develop an IAPP for P2 during the entirety of P2 receiving services from the license holder. P2 is no longer receiving services from the license holder. c. The license holder assessed P3 as susceptible to physical and sexual abuse. The license holder did not include a statement of specific measures that would be taken to minimize the risk of abuse in this assessed area. d. The license holder did not review P7’s IAPP with P7, P7’s legal representative, and P7’s interdisciplinary team annually in 2026. The license holder last reviewed P7’s IAPP in February 2025. e. The license holder assessed P8 as susceptible to self-abuse. The license holder did not include a statement of specific measures that would be taken to minimize the risk of abuse in all areas assessed. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2 Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · review and revise P1’s, P3’s, P7’s, and P8’s IAPPs to include the information listed above; · review the revised IAPP with P1’s, P3’s, P7’s and P8’s respective teams; · train all staff who work with P1, P3, P7 and P8 on their IAPPs and document that training in each staff person’s personnel record according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5; · maintain a list of the staff that have received training on P1’s, P3’s , P7’s and P8’s person served records. P2 no longer receives services from the license holder. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Violation: For one person whose record was reviewed (P7), the license holder did not provide service recipient rights as required. The license holder did not provide P7 or P7’s legal representative with a written notice that identified the services recipient rights in subdivisions 2 and 3 and an explanation of those rights annually in 2025. The license holder last provided these rights to P7 in May 2024. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, and annually thereafter, you must provide P7 or P7’s legal representative with the service recipient rights. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Violation: For one person whose record was reviewed (P7), the license holder did not provide services in response to the person’s identified needs, interests, preferences and desired outcomes comes as required. The license holder did not complete person-centered planning and delivery for P7 that identified what is important to P7, as well as what is important for P7, including preferences for when, how, and by whom direct support services are provided. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order that DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must · review and revise P7’s support plan addendum to reflect the above-mentioned information; · review the revised support plan with P7 and P7’s support team; · train all staff that work with P7 on the updated plan and document that training in each staff person’s personnel record according to the requirements in Minnesota Statute, section 245D.095, subdivision 5; and · maintain a list of all staff that received the training in P7’s person served record. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Violation: For two persons whose records were reviewed (P6 and P7), the license holder did not complete assessments as required. a. The license holder did not complete the following assessments for P6 annually in 2025: · P6’s ability to self manage health and medical needs to maintain or physical mental and emotional wellbeing including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self administration of medication or treatment orders, preventative screenings, and medical and dental appointments; · P6’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 · P6’s ability to self-manage symptoms of behavior that may other 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 safety of the person or others. b. The license holder did not complete the following assessments for P7 annually in 2026: · P7’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; · P7’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 · P7’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. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order that DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · complete the assessments as stated above. You must produce information about P6 and P7 that describes P6’s and P7’s overall strengths, functional skills and abilities and behaviors or symptoms in this assessment; · review this assessment with P6’s and P7’s respective support teams; · train all staff that work with P6 and P7 on the updated plan and document that training in each staff person’s personnel record according to the requirements in Minnesota Statute, section 245D.095, subdivision 5; and · maintain a list of all staff that received the training in P6’s and P7’s person served record. Compliance with this order with be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Violation: For one person whose record was reviewed (P2), the license holder did not complete service planning and delivery for an intensive service as required. The license holder did not complete a preliminary support plan addendum based on P2’s support plan within 15 days of service initiation. P2 no longer receives services from the license holder. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (a). 7. Violation: For three persons whose records were reviewed (P3, P6, and P7), the license holder did not develop supports and outcomes as required. a. The license holder did not consistently document the criteria for achievement for P3’s outcome. P3’s outcome was developed on October 29, 2025. In one area of the outcome, it documented the outcome would be implemented monthly and in a different area of the outcome it documented it would be implemented monthly. b. The license holder did not make changes to P6’s outcome after a progress report dated April 17, 2025, documented there would be a change in P6’s outcome. c. The license holder did not document the following supports and methods to be implemented to support P7 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being: · the projected starting date for implementing the supports and methods; and · the date by which progress towards accomplishing the outcomes would be reviewed and evaluated. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, and a Correction Order issued April 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · review and revise P3’s and P6’s outcomes to accurately identify the supports and methods for their outcomes; and · develop the above-mentioned information for P7. Compliance with this order will be monitored on site. On an ongoing basis, you maintain compliance with this subdivision as required. 8. Violation: For three persons whose records were reviewed (P1, P7, and P8), the license holder did not review and evaluate the service plan as required. a. The license holder did not discuss with P1 and members of their support team about how technology might be used to meet P1’s desired outcomes and options for transitioning out of a provider controlled setting in 2025. b. The license holder did not complete an annual review in 2025 with P7, P7’s legal representative, and P7’s case manager that included the following: · a discussion of how technology might be used to meet the person's desired outcomes, including a summary of this discussion, a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made; and · options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider, including a summary of the discussion, a statement about any decision made regarding transitioning out of a provider-controlled setting and a description of any further research or education that must be completed before a decision regarding transitioning out of a provider-controlled setting can be made. · a summary of the person's status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting. c. The license holder did not discuss with P8 and members of their support team about how technology might be used to meet P8’s desired outcomes in 2025. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. Repeat Violation: In an Order of Conditional License dated May 3, 2024, a Correction Orders that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order issued by DHS on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · discuss with P1 and P1’s support team and P8 and P8’s support team about how technology might be used to meet their desired outcomes. Summarize this discussion in P1’s and P8’s support plan addendums, including a statement in the summary regarding any decision made related to the use of technology including a description of any further research that must be completed before a decision can be made; · discuss with P1 and P1’s support team options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. Summarize this conversation in P1’s support plan addendum, including a statement about any decision made regarding transitioning out of a provider-controlled setting and a description of any further research or education that must be completed before a decision can be made; · begin collecting data for P6’s as written in their outcomes; and · complete an annual review with P7, P7’s legal representative, and P7’s case manager on the above-mentioned topics. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Violation: For two persons whose records were reviewed (P6 and P7), the license holder did not evaluate positive support strategies as required. The license holder did not review and evaluate the identified positive support strategies with P6 and P7 at least every six months. Rule Violated: Minnesota Rules Part 9544.0030, subpart 1. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, a Correction Order DHS issued on April 18, 2025, and a Correction Order DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must review and evaluate the positive supports strategies for P6 and P7 with P6 and P7. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not document outcomes as required. a. The license holder did not document P5’s progress or lack of progress towards each outcome or goal for P5. At the time of the review, the license holder had not collected any data for the outcome implemented in December 2025. b. The license holder did not document P6’s progress or lack of progress towards each outcome or goal for P6. The license holder did not collect data for P6’s outcome after August 2025. Rule Violated: Minnesota Rules 9544.0100, subpart 3. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · begin documenting P5’s and P6’s progress towards their respective outcomes; · train all staff on how to implement and track progress towards P5’s and P6’s respective outcomes, and document this training in each staff person’s personnel record according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5; · maintain a list of the staff training in P5’s and P6’s person served records. Compliance with this order will be monitored onsite. On ongoing basis, you must maintain compliance as required in this subdivision. HEALTH SERVICE NEEDS VIOLATION 11. Violation: For two people whose records were reviewed (P4 and P8), the license holder did not maintain documentation of how the person’s health needs would be met as required. a. The license holder was assigned the responsibility of meeting P4’s health service needs. The license holder did not maintain documentation on how P4’s health needs would be met, including a description of procedures the license holder will follow in order to monitor her dental health conditions according to written instructions from a licensed health professional. b. The license holder was assigned the responsibility of meeting P8’s health service needs. The license holder did not maintain documentation on how P8’s health needs would be met, including a description of the procedures the license holder will follow in order to: · provide medication setup, assistance, or administration according to this chapter; · monitor health conditions according to written instructions from a licensed health professional; or · assist with or coordinate medical, dental, and other health service appointments. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1 paragraph (b). Repeat Violation: In a Correction Order that DHS issued on April 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receiving this order, you must: · document the above mentioned information for P3, P4 and P8; · train all staff working with P3, P4, and P8 on their respective health needs, and document this training in each staff person’s personnel record according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5; and · maintain a list of all staff that received this training in P3’s, P4’s and P8’s service recipient record. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Violation: For one person whose record was reviewed (P2), the license holder did not document medication setup as required. The license holder was assigned responsibility for medication setup according to P2’s support plan addendum. The license holder did not document the date of setup in P2’s medication administration record (MAR). P2 no longer receives services from the license holder. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1a. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, and a correction order that DHS issued on April 25, 2025, you were previously found in violation of this same statute. 13. Violation: For one person whose record was reviewed (P6), the license holder did not document information in the person’s medication administration record (MAR) as required. The license holder was responsible for administering P6’s medications. The license holder did not document information needed to correctly administer P6’s medication. P6 was prescribed Naproxen 500mg tablets on February 24, 2026. P6 was prescribed one Naproxen 500mg tablet by mouth twice a day for 10 days. The license holder documented this on P6’s MAR as Naproxen Sodium 500mg tablet, twice daily as needed for pain. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), clause (1). Repeat Violation: In an Order of Conditional License dated May 3, 2024, a Correction Order that DHS issued on December 6, 2024, and a Correction Order dated April 18, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, you must review P6’s MAR to ensure all medications are documented correctly and administered as prescribed. Within 60 days of receipt of this order, you must: · train all staff on your safe medication and administration policy; · document this training in each staff persons personnel record according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5. · maintain a list of the staff persons who received this training. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Violation: For four persons whose records were reviewed (P1, P2, P4 and P6), the license holder did not document medication administration as required. a. The license holder was assigned the responsibility of medication administration for P1. The license holder did not document a notation of when a medication was administered or a notation of a dose of medication not being administered, whether by error by the staff or the person or by refusal by the person in over 200 instances between November 1, 2025 and February 28, 2026. b. The license holder was responsible for administering P2’s medications. The license holder did not document a notation of when a medication was administered or a notation of a dose of medication not being administered, whether by error by the staff or the person or by refusal by the person in over 150 instances between January 22, 2026 and February 10, 2026. c. The license holder was assigned the responsibility of checking P4’s blood glucose on Tuesday, Thursdays, and Saturdays after supper. The license holder did not document a notation of this treatment being administered or a notation of this treatment not being administered on nine occasions in October 2025. d. The license holder was assigned the responsibility of administering P6’s medications. The license holder did not document a notation of when a medication was administered or a notation of a dose of medication not being administered, whether by error by the staff or the person or by refusal by the person in over 10 occasions between September 1, 2025, and November 30, 2025. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2 paragraph (c), clauses (5) and (6). Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order that DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receipt of this order, you must: · train all staff that work with P1, P4, and P6 on how their health needs will be met, including a description of the procedures you will follow in order to provide medication administration to P1, P4, and P6, and document this training in each staff person’s personnel record according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5; and · maintain a list of the staff that received this training in P1’s, P4’s and P6’s service recipient records. P2 no longer receives services from the license holder. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Violation: For four persons whose records were reviewed (P1, P2, P4 and P6), the license holder did not review and report medication and treatment issues as required. a. The license holder did not complete MAR reviews for P1. The license holder was ordered to complete MAR reviews for P1 in a correction order dated April 18, 2025. At the time of the review on March 3, 2026, there were no MAR reviews conducted in P1’s person served record. b. The license holder did not report P2’s medication refusals or P2’s failure to take or receive medications as prescribed to P2’s case manager as they occurred. The license holder did not notify P2’s case manager on ten different days between January 22, 2026, and February 10, 2026, of occurrences when P2 did not take their medication as prescribed. c. The license holder maintained documentation in P4’s medication administration record of P4’s refusal to complete blood glucose monitoring in over 50 instances between September 1, 2025, and February 28, 2026. The license holder did not report treatment refusals to P4’s legal representative and case manager as they occurred. d. The license holder did not conduct a review of P6’s MAR at least every three months. The last review of P6’s MAR was dated April 1, 2025. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order that DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review P1’s, P4’s, and P6’s MARs from the past six months to current to ensure the information maintained in the MAR is current and to identify medication administration or treatment errors; · report any medication or treatment errors, including refusals, found in P1’s. P4’s, and P6’s MAR to their legal representative and case manager; · develop and implement a plan to correct patterns of errors, including refusals, and maintain this plan in the program’s records; and · maintain documentation of the notifications regarding the medication errors in P1’s, P4’s and P6’s record. P2 no longer receives services from the license holder. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Violation: For two persons whose records were reviewed (P3 and P6), the license holder did not maintain documentation regarding psychotropic medications as required. “Target symptom" refers to any perceptible diagnostic criteria for a person's diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. The license holder was responsible for administering P3’s and P6’s medications, including psychotropic medications. The license holder did not document a description of the target symptoms that each of P3’s and P6’s psychotropic medications were to alleviate. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, a Correction Order that DHS issued on December 6, 2024, a Correction Order that DHS issued on April 18, 2025, and a Correction Order that DHS issued on October 7, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 60 days or receipt of this order, you must document the target symptoms that each of P3’s and P6’s psychotropic medications are prescribed to alleviate. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. Record Keeping Violations 17. Violation: For one person whose record was reviewed (P6), the license holder did not maintain person served records as required. The license holder did not maintain daily progress notes for P6. There were over 100 days the license holder did not document daily progress notes between June 2025 and February 2026. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, and in a Correction Order issued by DHS on April 18, 2025, you were previously found in violation of this same statute. 18. Violation: The license holder did not ensure that the content and format of service recipient, personnel, and program records were uniform and legible according to this chapter. The license holder did not ensure the uniform organization of program records. The license holder’s offices had documents scattered about which resulted in the license holder having difficulty locating requested documents for the licensing review. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 1. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · develop a plan to archive all documentation in each person served file that is not part of their current support plan addendum; this plan must meet record keeping and retention requirements in Minnesota Statutes, section 245A.041, subdivision 3, and Minnesota Statutes, section 245D.095; o this plan must address how the documents scattered on the floor, in boxes, in three ring binders, and shelves will be organized to maintain a uniform record keeping system; · submit this plan to your licensor for approval. You must get approval from your licensor prior to implementing the new record keeping system. Within 60 days of receipt of this order, you must implement your record keeping system approved by your licensor. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required. 19. Violation: For one of four staff person whose records were reviewed (SP1), the license holder did not maintain personnel records as required. The license holder did not document the date SP1 received orientation to individual needs as it relates to the responsibilities assigned to the license holder, specifically training on the person’s support plan or the support plan addendum, and the person’s individual abuse prevention plan to achieve and demonstrate an understating of the person as a unique individual and how to implement these plans. DHS licensors could not determine if this training occurred prior to SP1 having unsupervised direct contact with person’s served by the program. Statutes Violated: Minnesota Statutes, section 245D.095, subdivision 5, and section 245D.09, subdivision 4a. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, a Correction Order DHS issued on April 18, 2025, and a Correction Order DHS issued on October 7, 2025, you were previously found in violation of this same statute. Nature, chronicity, or severity of violations and effect of violation(s) on health, safety, or rights of persons served by the program The Commissioner has considered the nature, chronicity, or severity of the violation(s) of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a conditional license is appropriate. · Nature: The license holder was issued an Order of Conditional License on May 3, 2024. In addition to the conditional status of this license, the license holder was issued three correction orders since May 3, 2024, that contained citations with corrective action ordered. While the license holder did complete some of the corrective action, the license holder did not implement and complete all of the corrective action to ensure the health, rights, and safety for the persons served. · Chronicity: Your program’s license has been on conditional status since May 3, 2024. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarized this history o April 24, 2026, Conditional License (this order): 19 violations (17 repeat) o October 7, 2025, Correction Order: 16 violations (16 repeat) o April 18, 2025, Correction Order: 22 violations (16 repeat) o December 6, 2024, Correction Order: 21 violations (16 repeat) o May 3, 2024, Conditional License: 25 violations (3 repeat) · Severity: Many of the violations involve your inability to complete service planning and delivery requirements, conduct ongoing evaluation of the services provided, and meet the assigned health services needs of the individuals you serve. During the conditional status, you have not demonstrated sufficient completion of service planning requirements and ongoing evaluation of services provided to person served. This could result in service recipient not receiving safe, adequate, and complaint services from competent and properly trained staff. Many of the violations listed in this order involve the health service needs of the individuals you serve, and all of them are repeat violations. You have not demonstrated that you have an understanding of how to assist with and administer medications when assigned this responsibility, which could affect the health and safety of the service recipients. You are not ensuring staff are consistently administering medications as evidence by the lack of documentation when medications are administered. You are not consistently reviewing medication administration records to ensure medications are listed correctly and to identify any medication administration errors. This has been cited throughout the time of the conditional license. The plans that you develop on how to meet the health needs of the persons served are lacking in documented descriptions of the procedures on how to provide health needs, which can lead to error during service delivery by the staff person. You did not complete each person’s IAPP accurately by not documenting vulnerabilities for each person. Assessing abuse risks and creating a plan to minimize such risk is not a mere technical exercise in regulatory documentation. The IAPP is a critical document that informs the safe provision of services to vulnerable adults. The IAPP also informs your staff how to prevent the risk of abuse and identifies positive support strategies staff can use in service delivery. You have repeatedly been cited for this since the conditional license was ordered. These violations relate to the health, safety, and well-being of persons served and put their health and safety at risk. You did not prepare outcomes and supports based on assessments of the person’s needs consistently throughout your program. Providing an intensive support service requires you to provide more than just supervision. You are required to assess the needs of persons served and to document supports and methods to assist the person in acquiring, retaining or improving skills. Without accurate data and clearly stated outcomes, it is impossible to determine if you are implementing outcomes that are assisting the person in acquiring, retaining or improving skills. You have been provided technical assistance in this area throughout the conditional license period. You did not show that you provided any services beyond basic support services when you were legally required and paid to provide intensive support services. The designated coordinator did not provide the coordination of service delivery and evaluation of individual service delivery. Corrective action was repeatedly ordered throughout the time of the conditional license and it was not completed. For example, you were cited three times for not completing documentation to the Office of the Ombudsman for Mental Health and Developmental Disabilities following an emergency use of manual restraint. In correction orders issued on December 6, 2024, April 18, 2025, and October 7, 2025, you were ordered to submit this documentation. You did not complete this until January 13, 2026. License holders are required to hire qualified and competent individuals for this role to ensure licensing compliance is maintained. As a result of your inability to hire a qualified and competent designated coordinator and designated manager, you were found in violation of the 19 citations described in this order. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the program’s operation, well-being of persons served by your program, the qualifications of staff persons, and the ability to demonstrate competent knowledge of applicable laws and rules. DHS is concerned about your program’s operation because since you were placed on a Conditional license, DHS has issued one conditional license with corrective action and four correction orders, and 19 licensing violations with 17 repeat violations were determined during the most recent licensing review. The number of violations and repeat violations demonstrates that you did not adequately oversee your responsibilities as a license holder, to ensure compliance, and to take corrective action when ordered by the Commissioner. DHS’ concerns about your program’s operation and competency are further evidenced by your failure to meet service planning and evaluation requirements. These standards are essential to protect the health and safety of individuals served and represent minimum expectations for license holders. Noncompliance limits the Commissioner’s ability to ensure legally required levels of care. Your lack of service planning and documented evaluations creates a risk that staff may be unaware of individuals’ unique needs. Additionally, you have not demonstrated the ability to evaluate services effectively, as you failed to implement required corrective actions outlined in DHS orders since being placed on a Conditional License on May 3, 2024. This lack of oversight raises serious concerns about the health, safety, and well-being of those in your care. Based on the Commissioner’s evaluation of the program, a conditional license is warranted. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of person served in your care, your license to provide Home and Community Based Services is on a conditional license. Corrective action required You must correct the violations as described above. If you do not demonstrate substantial compliance with Home and Community Based Services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the 19 violations (17repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. Since the violations involved your lack of competence to hire and train competent Designated Coordinators and Designated Managers; they involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). CONDITIONAL LICENSE TERMS In addition to the Home and Community Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must complete the corrective action in citation one above which includes the need to: · designate a staff person, other than SP4, to provide coordination and evaluation of individual service delivery; · designate a managerial staff person, other than SP4, to provide program management and oversight of the services provided by the license holder; and · submit the names and qualifications for the person(s) who will fulfill the duties and responsibilities of the designated coordinator and designated manager for DHS review and approval. The same person may work in both roles if they meet the necessary qualifications. You are responsible for ensuring the person(s) meet the necessary qualifications. You must maintain documentation of your designated coordinators and designated manager’s qualifications in their personnel record and a signed job description. Changes to these positions may not be made without prior notification and approval by DHS. 3. Within 60 days of order, you must · ensure corrective action outlined in citations 2 through 19 is completed; · submit a written plan to DHS detailing how you will audit all person served records for compliance with all applicable rules and statutes that include the roles and responsibilities of the designated coordinator and designated manager will have in auditing person served records; · submit the date to your DHS licensor that all person served, and personnel records will be brought into compliance based on the results of your audit. This date must be within 90 days of receiving this order; and · store the audits and any corrections made in each person’s service recipient record. 4. During the first three months of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, and documentation of compliance with term 1 of your conditional license. 5. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 6. You may not add additional services to this license for the duration of the conditional license. 7. You will not be granted any variances for the duration of the conditional license. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at diana.arnzen@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Diana Arnzen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for one year from that date. You continue to be required to comply with all Home and Community Based Services laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home Community Based Services are required to follow Minnesota Statutes 245A, 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Leota Bemis, Supervisor, at 651-431-5637. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
|
