April 21, 2026

Ahmed Mahmud, Authorized Agent

Beacon Community Care LLC

4836 Nord Drive

Minneapolis, MN 55437

License Number: 1111346 (245D – HCBS)

CORRECTION ORDER

Dear Ahmed Mahmud

On March 18, 2026, a licensing review of Beacon Community Care LLC, located at 7825 Washington Avenue South, Minneapolis, 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 two of four persons whose records were reviewed (P2 and P4), the license holder did not establish and review individual abuse prevention plans (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 P2 as susceptible to physical abuse and self-abuse . The license holder did not include a statement of the specific measures that would be taken to minimize the risk of physical abuse and self-abuse to P2.

Additionally, the license holder did not review and evaluate P2’s individual abuse prevention plan (IAPP) annually in 2025, as required.

b. The license holder did not review and evaluate P4’s individual abuse prevention plan with P4 and P4’s support team annually in 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P2’s IAPP to document a statement of the specific measures that will be taken to minimize the risk for all areas P2’s is assessed as susceptible to abuse;

· train all staff providing direct support services to P2 on P2’s revised IAPP;

· document this training in each staff’s personnel record;

· review P4’s IAPP with P4 and their support team and revise as necessary to reflect the results of the review;

· maintain documentation of this review in P4’s record;

· audit all person served records to ensure that all the above has been completed for all persons served; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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 one person whose record was reviewed (P4), the license holder did not provide a written notice that identified the service recipient rights as required.

The license holder did not provide P4 with a notice and explanation of the service recipient rights annually in 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must provide P4 with a copy of the service recipient rights and am explanation of those rights and maintain documentation of the receipt of the rights. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required.

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

Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not meet health service needs as required.

a. The license holder did not maintain documentation of how P3’s health needs would be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health service appointments.

b. The license holder did not maintain documentation of how P4’s health needs would be met, including a description of the procedures the license holder would follow in order to assist with or coordinate medical, dental, and other health service appointments and monitor health conditions according to written instructions from a licensed health professional.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P3’s and P4’s support plan addendum to document the above health needs;

· train all staff providing direct support services to P3 and P4 on P3’s and P4’s revised support plan addendums;

· document this training in each staff’s personnel record;

· audit all person served records to ensure that all the above has been completed for all persons served; and

· maintain documentation of the audit results.

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

Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not provide services as assigned.

a. The license holder did not provide P2’s services as assigned in the support plan. P2’s support plan assigned the license holder to assist P2 with “paperwork, appointments, organization, resources and problem solving.” The license holder maintained log notes that documented that assistance in these areas was not provided to P2.

b. The license holder did not provide IHS with family training to P4 in compliance with the requirements of the federal waiver plan. The license holder maintained log notes that documented multiple occasions between September 2025 and March 2025 in which services provided to P4 did not include covered services documented in the Community Based Service Manual (CBSM) for IHS with family training.

Corrective Action Ordered: Immediately upon receiving this order, you must provide services to P2 and P4 as assigned in P2’s and P4’s support plans and support plan addendums and in compliance with the federal waiver plans. Compliance with this order will be reviewed 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 2.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete service planning for basic support services as required.

a. The license holder initiated respite with P1 on July 2, 2025. The license holder did not review and revise P1’s preliminary support plan addendum within 60 calendar days of service initiation of respite to document the services 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. At the time of the licensing review this had not been completed.

b. The license holder did not participate in service planning and support team meetings annually in 2024 and 2025 for P2 as assigned. The license holder documented in P2’s support plan addendum that meetings with P2 and P2’s support team would be conducted annually. The license holder initiated P2’s services on December 31, 2023. The license holder did not conduct a meeting with P2 and P2’s support team until February 11, 2026.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P1’s support plan addendum for respite to document the above;

· train all staff providing direct support services to P1 on P1’s revised support plan addendum;

· document this training in each staff’s personnel record;

· audit all person served records to ensure that all the above has been completed for all persons served receiving basic services; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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 3.

Violation: For one person whose record was reviewed (P2), the license holder did not provide progress reports for basic services as required.

The license holder did not provide written reports to P2’s case manager regarding P2’s progress or status annually in 2025. The license holder documented in P2’s support plan addendum that progress reports would be provided annually. The license holder last provided a progress review report on October 7, 2024.

Corrective Action Ordered: Within 60 days of receiving this order, you must

· provide a written report regarding P2’s progress or status to P2’s case manager as assigned;

· audit all person served records to ensure that all the above has been completed for all applicable persons served; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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.071, subdivision 3, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not complete assessments as required.

a. The license holder initiated individualized home supports with family training for P1 on July 2, 2025. The license holder did not complete assessments for P1 in the following areas before providing 45 days of service or within 60 calendar days of service initiation:

· 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;

· 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; and

· the assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms.

b. The license holder initiated individualized home supports with family training for P4 on December 4, 2024. The license holder did not complete assessments for P4 in the following areas before providing 45 days of service or within 60 calendar days of service initiation:

· 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;

· 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;

The license holder completed these assessments for P4 on October 8, 2025. The license holder’s assessment did not produce information about P4 that describes the person’s overall strengths, functional skills and abilities and behaviors or symptoms. Additionally, the license holder did not review P4’s assessments with P4 and P4’s support team annually in 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· complete the above mentioned assessments for P1;

· train all staff providing direct support services to P1 on P1’s assessments;

· document this training in staff’s personnel record;

· complete the above mentioned assessments for P4 that produce information about the person that describes their overall strengths, functional skills and abilities and behaviors or symptoms;

· review the results of P4’s assessments with P4 and P4’s support team. You must document this review;

· train all staff providing direct support services to P4 on P4’s assessments;

· document this training in each staff’s personnel record;

· audit all person served records to ensure that assessments have been completed for all persons served receiving intensive services; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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, paragraphs (b) and (c).

Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not complete initial service planning for intensive services as required.

a. The license holder did not hold an initial planning meeting with P1, P1’s legal representative, P1’s case manager and other members of the support team before providing 45 days of service or within 60 calendar days of service initiation to determine:

· the scope of the services to be provided to support the person's daily needs and activities;

· the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

· the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule;

· whether the current service setting is the most integrated setting available and appropriate for the person;

· opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences;

· opportunities for community access, participation, and inclusion in preferred community activities;

· opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community;

· opportunities to seek competitive employment and work at competitively paying jobs in the community;

· how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and

· how technology might be used to meet the person's desired outcomes.

b. The license holder did not hold an initial planning meeting with P4, P4’s case manager and other members of the support team before providing 45 days of service or within 60 calendar days of service initiation to determine:

· the scope of the services to be provided to support the person's daily needs and activities;

· the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes;

· the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule;

· whether the current service setting is the most integrated setting available and appropriate for the person;

· opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences;

· opportunities for community access, participation, and inclusion in preferred community activities;

· opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community;

· opportunities to seek competitive employment and work at competitively paying jobs in the community;

· how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and

· how technology might be used to meet the person's desired outcomes.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· hold a meeting with P1, P1’s legal representative, and P1’s case manager and P4, P4’s case manager and members of their support team to determine the above;

· train all staff providing direct support services to P1 and P4 on P1’s and P4’s revised support plan addendums;

· document this training in each staff’s personnel record;

· audit all person served records to ensure that above has been completed for all persons served receiving intensive services; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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 4.

Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not complete service outcomes and supports as required.

a. The license holder did not develop a service plan that documented service outcomes and supports for P1.

b. The license holder did not document the following supports and methods for P4’s desired outcomes:

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

o any equipment and materials required; and

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

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

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· develop a service plan for P1 that documents the service outcomes and supports;

· develop a service plan that documents the service outcomes, and supports and methods listed above for P4;

· train all staff providing direct support to P1 and P4 on P1’s and P4’s outcomes and supports;

· document this training in each staff’s personnel records;

· audit all person served records to ensure the above has been developed for all persons served receiving intensive services; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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 5, paragraph (g).

Violation: For one person whose record was reviewed (P4), the license holder did not meet the requirements for service plan review and evaluation for intensive services as required.

The license holder documented in P4’s support plan addendum that progress reports and progress review meetings would be completed annually. The license holder did not provide progress reports for P4 annually. Additionally, the license holder did not meet with P4, P4’s case manager and other members of P4’s support team annually in 2025.

Corrective Action Ordered: Within 60 days of receiving this order, you must provide P4 and members of P4’s support team with a progress report summarizing the person’s status and progress toward achieving their identified outcomes, make recommendations, and identify the rational for changing, continuing or discontinuing implementation of the support and methods identified in subdivision 4. You must maintain a copy of this progress review report in P4’s record. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Rules, Part 9544.0030, subpart 1.

Violation: For four persons whose records were reviewed (P1-P4), the license holder did not evaluate positive support strategies as required.

The license holder did not evaluate identified positive support strategies with P1, P2, P3 and P4 at least every 6 months.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· evaluate the identified positive support strategies with P1-P4 and document the evaluation in the person’s support plan addendum; and

· based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes.

Compliance with this order will be reviewed 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 4.

Violation: For three of five staff persons whose records were reviewed (SP1-SP3), the license holder did not provide and ensure completion of orientation training as required.

a. The license holder hired SP1 on September 28, 2025. The license holder did not provide SP1 with orientation in the following areas within 60 days of hire:

· the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· 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;

· 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;

· basic first aid; and

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

b. The license holder hired SP2 on October 20, 2025. The license holder did not provide SP2 with an orientation to the following topics within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under 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 this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

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

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 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;

· 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;

· 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.

c. The license holder hired SP3 on September 25, 2024. The license holder did not provide SP3 with an orientation to the following topics within 60 days of hire:

· the job description and how to complete specific job functions, including:

o responding to and reporting incidents as required under 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 this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

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

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 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;

· 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;

· 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 60 days of receiving this order, you must:

· provide and ensure completion of the above training for SP1, SP2, and SP3;

· audit all staff personnel records to ensure completion of the above training; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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.09, subdivision 4a.

Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation to the individual service recipient needs as required.

The license holder did not provide SP1-SP3 with review and instruction on the following before having unsupervised contact with persons served by the program:

· the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and to implement the plans; and

· the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement the plan.

At the time of the licensing review this had not been provided to SP1-SP3.

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

· provide SP1, SP2, and SP3 with the above training;

· audit all staff personnel records to ensure the above training has been provided; and

· maintain documentation of the audit results.

Compliance with this order will be reviewed 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.09, subdivision 5.

Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide annual training as required.

The license holder did not provide SP3 with annual training as required in the following areas in 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;

· 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;

· 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: Refer to citation 13 for corrective action. On an ongoing basis, you must maintain compliance as required in this subdivision.

15. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not maintain personnel records as required.

a. The license holder did not maintain documentation in SP1’s personnel record or elsewhere, sufficient to determine SP1’s date of first supervised contact with a person served by the program.

b. The license holder did not maintain a personnel record for SP2 that included:

· the employee’s completed application, an acknowledgment signed by the employee that job duties were reviewed with the employee and the employee understands those duties, and documentation that the employee meets the position requirements as determined by the license holder;

· documentation of staff qualifications, orientation, and training; and

· the date of the employee’s first supervised direct contact with a person served by the program.

c. The license holder did not maintain a personnel record for SP3 that included:

· The employee’s date of hire;

· documentation of staff qualifications, orientation, and training; and

· the date of the employee’s first supervised and unsupervised direct contact with a person served by the program.

Corrective Action Ordered: Within 60 days of receiving this order, you must document the above mentioned information in SP1’s, SP2’s and SP3’s personnel records. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.10, subdivision 2.

Violation: The license holder did not establish grievance policies and procedures as required.

The license holder did not establish grievance policies and procedures that provided the address of that highest level of authority in the program.

Corrective Action Ordered: Immediately upon receiving this order you must review and revise your grievance policies and procedures to include the address of the highest level of authority in the program. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

17. Citation: Minnesota Statutes, section 245A.65, subdivision 1.

Violation: The license holder did not maintain written policies and procedure related to suspected or alleged maltreatment as required.

The license holder did not identify a secondary person or position to whom internal reports would be made and who would be responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5. Additionally, the license holder did not identify a secondary person or position who would ensure that, when required, internal reviews are completed.

Corrective Action Ordered: Immediately upon receiving this order, you must review and revise your policies and procedures related to suspected or alleged maltreatment to identify the above persons or positions. Compliance with this order will be reviewed at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

18. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Violation: The license holder did not ensure the designated coordinator (SP4) and the designated manager (SP5) provided program management and oversight of the services provided by the license holder as required.

a. The license holder did not ensure that the staff person the license holder identified as the designated coordinator (SP4) 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 have been achieved according to the requirements in section 245D.07.

b. The license holder did not ensure that the staff person the license holder identified as the designated manager (SP5) performed the required 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 (b);

· ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; and

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

Citations 1 through 17 are evidence of the license holder’s lack of program coordination, program management, and oversight of the services provided.

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

· designate a person other than SP4 to perform the duties of the designated coordinator that meets the qualifications according to Minnesota Statutes, section 245D.081, subdivision 2;

· designate a person other than SP5 to perform the duties of the designated manager that meets the qualifications according to Minnesota Statutes, section 245D.081, subdivision 3;

· verify and document their qualifications according to the requirements in section 245D.09, subdivision 3, including the education and work qualifications in section 245D.081, subdivisions 2 and 3; and

· submit the name and verifiable qualifications of the individual who will be acting in the designated coordinator and designated manager role to your licensor for approval.

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

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.

Robert Romani, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-3658

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