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April 27, 2026 Mai Lee Vang, Authorized Agent Essential Home LLC 2993 Beebe Parkway Maplewood, Minnesota 55109 License Number: 1113441 (245D – HCBS) CORRECTION ORDER Dear Mai: On March 27 and April 1, 2026, a licensing review of Essential Home LLC located at 2345 Rice Street Suite 245, Roseville, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c). Violation: For one of four persons whose record was reviewed (P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment as required. The license holder provided multiple services to P2. The license holder did not provide P2 with orientation to the license holder’s internal and external reporting procedures related to alleged or suspected maltreatment within 24 hours of admission of night supervision. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2 with the orientation to the above-mentioned reporting procedures and notify P2’s legal representative of this orientation. 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 245A.65, subdivision 2. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not establish and enforce 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 maintained an IAPP for P1 dated May 2, 2025. The license holder did not develop an IAPP for P1 that included an individualized assessment of P1’s susceptibility to financial abuse. During the licensing review, the license holder reported that P1 was susceptible to financial abuse. b. The license holder provided multiple services to P2. The license holder maintained an IAPP for P2 dated September 1, 2024. The license holder did not develop an IAPP for P2 that included specific actions the program would take to minimize the identified risks of abuse within the scope of the licensed services, including night supervision, in P2’s IAPP. Additionally, the license holder did not review P2’s IAPP with P2’s interdisciplinary team annually in 2025. c. The license holder maintained an IAPP for P3 dated July 2, 2024. The license holder did not develop an IAPP for P3 that included an individualized assessment of P3’s susceptibility to self-abuse, physical abuse and financial abuse. P3’s IAPP was not consistent with information maintained in P3’s record. P3’s record indicated that P3 required support in these areas to be able to live in the community safely. Additionally, the license holder did not review P3’s IAPP with the P3’s interdisciplinary team annually in 2025. d. The license holder maintained an IAPP for P4 dated July 17, 2025. The license holder did not develop an IAPP for P4 that included an individualized assessment of P4’s susceptibility to self-abuse, and physical abuse. P4’s record indicated that P4 needed support for community participation, health, safety, and adaptive skills including crisis prevention skills, and problem solving. Corrective Action Ordered: Within 30 days of receiving this order, you must: · revise P1’s, P3’s, P4’s IAPPs to accurately assess each person’s susceptibility to abuse; · revise P2’s IAPP to include specific actions the program would take to minimize the identified risks of abuse within the scope of the licensed services; · review each person’s revised IAPP with the person and their interdisciplinary team and maintain documentation of this review in their records; and · provide instruction on the revision of P1’s, P2’s, P3’s, and P4’s IAPPs to all staff that provide direct support to P1, P2, P3, and P4 and maintain documentation in accordance with Minnesota Statutes 245D.095. 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. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide written notice of the service recipient rights as required. Minnesota statues, 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 P2 or P2’s legal representative a written notice that identified the service recipient rights and an explanation of those rights within five working days of P2’s service initiation for night supervision. b. The license holder initiated individualized home supports service with training and provided the service recipient rights on September 1, 2024. The license holder did not provide P2 or P2’s legal representative with a written notice that identified the service recipient rights annually in 2025. c. The license holder did not provide P3 a written notice that identified the service recipient rights and an explanation of those rights annually. The license holder most recently provided P3 the service recipient rights in July 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P2 or P2’s legal representative, and P3 a written notice that identifies the service recipient rights and an explanation of those rights; and · maintain documentation of receipt of a copy and an explanation of the rights for P2 and P3. 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.04, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not document the rights restriction as required. The license holder did not include the following information for a restriction on P2’s right to engage in chosen activities at any time: · the justification for the restriction based on an assessment of P2's vulnerability related to exercising the right without restriction; and · the objective measures set as conditions for ending the restriction; · a schedule for reviewing the need for the restriction based on the conditions for ending the restriction, to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by P2, P2's legal representative, or P2’s case manager. Corrective Action Ordered: Within 30 days, you must determine if a restriction of P2’s right to chosen activities at any time is necessary to ensure P2’s health, safety, and well-being. If it is determined a rights restriction is necessary for P2, you must document the following: · the justification for the restriction based on an assessment of P2’s vulnerability related to exercising the right without restriction; · the objective measures set as conditions for ending the restriction; · a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at minimum; and · signed approval for the restriction from P2’s legal representative. 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.05, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not document health service needs as required. The license holder was assigned medication assistance in P1’s support plan. The license holder did not document how P1’s needs would be met, including a description of the procedures the license holder would follow in order to meet these health needs. Additionally, the license holder reported P1 requires assistance to schedule rides for medical appointments. The license holder did not document how P1’s health needs would be met regarding scheduling rides for medical appointments. Corrective Action Ordered: Within 30 days of receiving this order, you must document how P1’s health needs will be met including a description of the procedures the license holder will follow in order to meet these health needs. 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 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 did not review and revise P1’s support plan addendum within 60 calendar days of service initiation, 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. b. The license holder provided multiple services to P2. The license holder did not review and revise P2’s support plan addendums within 60 calendar days of service initiation for P2’s night supervision, 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. c. The license holder did not participate in service planning and support team meetings for P1 every six months as requested by P1's case manager. Corrective Action Ordered: Within 30 days of this order, you must: · meet with P1 and the expanded support team; · review and revise P1’s and P2’s support plan addendums to ensure the support plan addendums include the above-mentioned information for each service that they are receiving; · train staff who provide direct support services to P1 and P2 on their revised support plan addendums and maintain documentation in accordance with Minnesota Statutes 245D.095; and · maintain documentation of the review and revision in each person’s service recipient 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. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain a service recipient record as required. The license holder did not maintain progress or daily log notes for P1, P2, P3, and P4. Corrective Action Ordered: 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 Statues, section 245D.10, subdivision 4, paragraph (b). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not inform and provide copies of policies and procedures as required. a. The license holder did not inform P1’s, P3’s, and P4’s case managers of the policies and procedures affecting a person’s rights and did not provide copies of the policies and procedures to their case managers within five working days of service initiation. Including: • grievance policy and procedure; and • service suspension and termination policy and procedure. b. The license holder did not inform P2 or P2’s legal representative, and P2’s case manager of the policies and procedures affecting a person’s rights and did not provide copies of the policies and procedures within five working days of service initiation for night supervision. Including: • grievance policy and procedure; and • service suspension and termination policy and procedure Correction Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the policies and procedures detailed above to P1’s case manager, P3’s case manager, P4’s case manager, and P2’s legal representative and P2’s case manager. 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 Rules, 9544.0030 subpart 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not incorporate positive support strategies as required. a. The license holder did not evaluate the identified positive support strategies with P2 at least every six months. b. The license holder did not incorporate positive support strategies in writing to an existing plan for P3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate the identified positive support strategies with P2, document the evaluation in P2’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; and · assess P3’s strengths, needs, and preferences to identify and create a positive support strategy and incorporate these positive support strategies in writing to P3’s plan. 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 subpart. 10. Citation: Minnesota Rules, 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide notice of the license holder’s policy on the use of manual restraints as required. The license holder provided multiple services to P2. The license holder did not obtain a written acknowledgement from P2’s legal representative that they had been notified of the license holder’s emergency use of manual restraints policy and their rights under this chapter and Minnesota Statutes, sect 245D.04. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written acknowledgement from P2’s legal representative that they were notified of your policy on emergency use of manual restraint; and · maintain documentation of this notice being provided in their service recipient 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 these subparts. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. The license holder did not provide and ensure completion of orientation sufficient to create staff competency for SP1 and SP2 in the following areas: · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe, and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Immediately, you must provide SP1 and SP2 with the above-mentioned required training. On an ongoing basis, you must maintain compliance as required in these subdivisions.
12. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three of four staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain personnel records as required. a. The license holder did not maintain a personnel record for SP1 that included documentation sufficient to determine the date of SP1’s first unsupervised direct contact with the person served, and documentation of orientation and training that included: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor b. The license holder did not maintain a personnel record for SP2 and SP3 that included documentation of orientation and training, that included: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: The license holder did not provide program coordination and evaluation as required. The license holder did not ensure the designated coordinator, SP1, provided program supervision, support and evaluation of activities provided by the license holder. Citations 1 through 12 are evidence of the license holder’s lack of program coordination and evaluation of the services provided including: · 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 outcome has been achieved according to the requirements in section 245D.07. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete an audit of service recipient and personnel records; · based on the results of your audit, bring service recipient and personnel records into compliance in the areas identified as noncompliant through the audit; · develop and document a written plan for how you will come into compliance in all areas listed in this correction order; and · maintain documentation of these audits and the written plan in your records for future review by licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not provide program management and oversight as required. The license holder did not ensure the designated manager, SP4, provided program management and oversight of the services provided by the license holder. Citations 1 through 13 are evidence of the license holder’s lack of program management and oversight of the services provided including: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program; · ensuring the duties of the designated coordinators are fulfilled; · evaluation of satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress toward accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04; and · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete an audit of service recipient and personnel records; · based on the results of your audit, bring service recipient and personnel records into compliance in the areas identified as noncompliant through the audit: · develop and document a written plan for how you will come into compliance in all areas listed in this correction order; and maintain documentation of these audits and the written plan in your records for future review by licensor On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Nichol Ginther, Human Services Licensor Licensing Division Office of Inspector General 651-431-4822
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