Minnesota

May 5, 2026

Silas Kfusalu, Authorized Agent

Bright Vision Healthcare LLC

670 Commerce Drive Suite 240

Woodbury, Minnesota 55125-9248

License Number: 1107294 (245D – Home and Community-Based Services)

CORRECTION ORDER

Dear Silas Kfusalu:

On March 18, 2026, a licensing review of Bright Vision Healthcare LLC, located at 670 Commerce Drive Woodbury, 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 245D.061, subdivision 9.

Violation: The license holder did not establish written policies and procedures for emergency use of manual restraint as required.

The license holder did not develop, document, and implement a policy and procedure regarding the emergency use of manual restraints. The license holder maintained two contradictory policies and procedures on the emergency use of manual restraint, one policy that allowed the emergency use of manual restraint and one that did not allow the emergency use of manual restraint.

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

· review and revise your emergency use of manual restraint policies and procedures and implement consistently throughout your program;

· provide all persons served, persons served legal representatives, person served case managers, and staff with review and instruction on your emergency use of manual restraint policies and procedures; and

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

Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Rule, 9544.0030, subpart 1.

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

a. The license holder did not incorporate positive support strategies for P1, P2 and P3 in writing to an existing treatment, service, or other individual plan.

b. The license holder did not evaluate, at least every six months, whether P4’s identified positive support strategies met the standards in subpart 2.

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

· assess P1’s, P2’s, and P3's strengths, needs, and preferences to identify and create a positive support strategy and at least every six months, evaluate whether the identified positive support strategies currently met the standards in subpart 2;

· evaluate with P4 whether the identified positive support strategies currently meet the standards in subpart 2, and based on the results of this evaluation, determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes; and

· train staff on P1’s, P2’s, P3’s, and P4’s positive support strategies and maintain documentation according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide orientation to the policies and procedures related to suspected or alleged maltreatment.

The license holder did not provide P1-P4 with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder initiated P4’s services on January 1, 2025, and provided P4 with this orientation on February 25, 2025.

Corrective Action Ordered: Within 60 days of receiving this order you must provide P1-P3 with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults and maintain documentation of this orientation according to Minnesota Statutes 245D.095. Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245A.65, subdivision 2.

Violation: For two persons whose records were reviewed (P3 and P4), the license holder did not establish written individual abuse prevention plans (IAPP) as required.

a. The license holder did not develop P3’s IAPP at service initiation as a part of the initial individual service plan.

b. The license holder did not develop P4’s IAPP at service initiation as a part of the initial individual service plan. The license holder initiated P4’s services on January 1, 2025, and developed P4’s IAPP on February 25, 2025. The license holder did not include in P4’s IAPP the areas P4 was susceptible to abuse as defined in P4’s county support plan. The license holder did not complete a review of P4’s IAPP with their interdisciplinary team annually in 2026.

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

· develop P3’s IAPP with P3, P3 shall participate in the development of the IAPP to the full extent of their abilities

· review and revise P4’s IAPP;

· ensure P3’s and P4’s IAPP’s include the following:

a. a statement of the measures that will be taken to minimize the risk of abuse to when the individual assessment required in section 6926.557, subdivision 14, paragraph (b), indicates the need for the measures;

b. the specific actions the program will take to minimize the risk of abuse within the scope of the licensed service;

c. identify referrals made when P3 and P4 are susceptible to abuse outside the scope or control of the licensed services; and

d. when the assessment indicates that P3 and P4 do not need specific risk reduction measures the IAPP shall document this determination;

· review P3’s and P4’s IAPP with P3’s and P4’s interdisciplinary team and revise the plan to reflect the results of this review; and

· provide P3 and P4’s staff with training on their updated support plan addendums and maintain documentation according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site 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.04, subdivision 1.

Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide service recipient rights as required.

The license holder did not provide a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights to P1, P2, P3, and P4 within five working days of service initiation. Additionally, the license holder did not provide P4 this written notice annually in 2026.

Corrective Action Ordered: Within 60 days of receiving this order you must provide P1, P2, P3 and P4 with a written notice that identifies their service recipient rights and an explanation of those rights and maintain documentation of their receipt of a copy and an explanation of the rights. Compliance will be monitored on-site 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 1.

Violation: For one person whose record was reviewed (P4), the license holder did not provide service planning and delivery as required.

The license holder did not provide services as assigned in P4’s support plan. The license holder assigned themselves responsibility to provide P4 with Individual Community Living Supports (ICLS) and did not comply with the requirements of this chapter and the federal waiver plan. The license holder did not maintain documentation of the completed and signed ICLS planning form.

Corrective Action Ordered: Within 60 days of receiving this order you must communicate with P4 and P4’s case manager to identify the specific components P4 will receive, sign the completed form, and maintain documentation of the signed completed form in P4’s support plan addendum. Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide basic service planning as required.

a. The license holder did not complete a preliminary support plan addendum for P1, P2 and P3.

b. The license holder did not complete a preliminary support plan addendum for P4 within 15 calendar days of service initiation. The license holder initiated services with P4 on January 1, 2025, and completed P4’s preliminary support plan addendum on February 25, 2025.

c. The license holder did not review and revise P4’s preliminary support plan addendum within 60 days of service initiation to document the services that will be provided.

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

· complete P1, P2 and P3’s preliminary support plan addendum based on P1, P2 and P3’s support plan;

· review and revise P4’s preliminary support plan addendum to document how services will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services; and

· provide P1’s-P4’s staff with training on their updated support plan addendums and maintain documentation according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site 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.

Violation: For one person whose record was reviewed (P1), the license holder did not complete intensive support service planning as required.

The license holder did not complete:

· a preliminary support plan addendum based on the support plan for P1 within 15 days of service initiation; and

· P1’s assessments in the following areas before providing 45 days of service or within 60 calendar days of service initiation:

o P1’s ability to self-manage health and medical needs to maintain or improve physical, mental and emotional well-being, including, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments;

o P1's ability to self-manage personal safety to avoid injury or accident in the service setting, including, community survival skills, water safety skills, and sensory disabilities; and

o P1'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.

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

· complete a preliminary support plan addendum as described above and provide P1’s staff with training on their updated support plan addendum;

· complete the assessments listed above for P1 and review the results with P1 and their support team or expanded support team and document the review with P1’s support team in P1’s record; and

· provide P1’s staff with training on their updated support plan addendums and maintain documentation according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not meet the service planning and delivery requirements for intensive support services as required.

The license holder did not meet with P1, P1’s case manager, and other members of the support team before providing 45 days of service to determine the following requirements:

· the scope of services to be provided to support P1’s daily needs and activities;

· P1’s preferences for how services and supports are provided, including how the provider will support P1 to have control of P1’s schedule;

· whether the current service setting is the most integrated setting available and appropriate for P1;

· opportunities to develop and strengthen personal relationships with other persons of P1’s choice in the community;

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

· 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 P1 and members of the support team or expanded support team to ensure continuity of care and coordination of services for P1; and

· a discussion of how technology might be used to meet P1’s desired outcomes.

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

· meet with P1 and P1’s case manager, and other members of the support team to meet the service planning and delivery requirements for intensive services as detailed above;

· within ten working days of the service planning meeting develop a service plan that documents service outcomes and supports including the supports and methods to be implemented to support P1 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being:

o the methods or actions that will be used to support P1 and to accomplish the service outcomes, including information about:

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

· any equipment and materials required; and

· techniques that are consistent with P1’s communication mode and learning style;

o the measurable and observable criteria for identifying when the desired outcome has been achieved;

o how data would be collected;

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

o the names of the staff or position responsible for implementing the supports and methods;

· maintain a summary of discussion of how technology might be used to meet P1’s desired outcomes in P1’s support plan addendum that included a statement in the summary regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made; and

· provide P1’s staff with training on their updated support plan addendum and maintain documentation according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site 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.095, subdivision 3.

Violation: For four persons whose records were reviewed (P1 - P4), holder did not maintain service recipient records as required.

The license holder did not maintain copies of written reports regarding P1’s, P2’s, P3’s, and P4’s status when requested or daily log notes that are recorded by the program in P1’s, P2’s, P3’s and P4’s service recipient record.

Additionally, the license holder was assigned responsibility for meeting P4’s health service needs according to section 245D.05 and did not maintain the following information, as required in this subdivision, in P4’s service recipient record:

· a signed authorization from the person or the person's legal representative to administer or assist in administering the medication or treatments;

· a signed statement authorizing the license holder to act in a medical emergency when the person's legal representative, if any, cannot be reached or is delayed in arriving;

· medication administration procedures; and

· a medication administration record documenting the implementation of the medication administration procedures.

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

· maintain the documentation identified above in P1’s, P2’s, P3’s and P4’s service recipient records;

· audit all persons served files to ensure compliance with this subdivision and maintain documentation of the audit in the persons served file; and

· as needed, provide staff with training on updated service recipient records and maintain documentation of this training according to Minnesota Statutes 245D.095.

Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide copies of policies and procedures as required.

a. The license holder did not provide P1 and P1’s case manager with copies of the following policies and procedures affecting a person’s rights within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restrains policy and procedure; and

· data privacy.

b. The license holder did not provide P2 and P2’s case manager, P3 and P3’s case manager, and P4 and P4’s case manager with copies of the following policies and procedures affecting a person’s rights within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restrains policy and procedure.

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

· provide P1 and P1’s case manager with copies of the policies and procedures identified above;

· provide P2 and P2’s case manager, P3 and P3’s case manager, and P4 and P4’s case manager with copies of the policies and procedures identified above; and

· maintain documentation of receipt in the service recipient’s file.

Compliance will be monitored on-site 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 two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide program orientation as required.

a. The license holder did not provide and ensure SP1 completed orientation that combined review and instruction in the following areas:

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

o responding to and reporting incidents as required under Minnesota Statutes, section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

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

· data privacy requirements according to Minnesota Statutes, section 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, 626.556, and 626.557, 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 according to section 245A.65, subdivision 3;

· the principles of person-centered planning and delivery as identified in Minnesota Statutes, 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 did not provide and ensure SP2 completed orientation that combined review and instruction in the following areas:

· 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;

· 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;

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

· basic first aid; and

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

c. The license holder did not provide SP2 with orientation to 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 within 72 hours of first providing direct contact services. The license holder maintained documentation that SP2 first had unsupervised contact with a person served by the program on December 11, 2023, and was provided this orientation on December 13, 2024.

Corrective Action Ordered: Within 60 days of receiving this order you must provide SP1 and SP2 with orientation on the topics identified above in (a) and maintain documentation according to Minnesota Statutes 245D.095. Compliance will be monitored on-site 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 two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required.

a. The license holder did not provide and ensure SP1 reviewed and received instruction on P1’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder.

b. The license holder did not provide and ensure SP2 reviewed and received instruction on P4’s medication assistance procedures.

Corrective Action Ordered: Within 60 days of receiving this order you must provide SP2 with review and instruction on P4’s medication assistance procedures and maintain documentation according to Minnesota Statutes 245D.095. Compliance will be monitored on-site 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 (SP2), the license holder did not provide annual training as required.

"Annual" or "annually" means prior to or within the same month of the subsequent calendar year.

The license holder did not provide SP2 with annual training in 2025 to 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.

Corrective Action Ordered: Within 60 days of receiving this order you must provide SP2 with the annual training identified above and maintain documentation according to Minnesota Statutes 245D.095. Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required.

The license holder did not maintain a personnel record for SP1 and SP2 that included documentation of orientation and trainings, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Additionally, the license holder did not maintain a personnel record for SP2 that included documentation of staff qualifications.

Corrective Action Ordered: Compliance will be monitored on-site 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.081.

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

a. The license holder did not ensure that the designated coordinator (SP3), provided supervision, support, and evaluation of activities that include:

· 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 services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07.

b. The license holder did not ensure that the designated manager (SP3) provided program management and oversight of the services provided by the license holder that include:

· maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g);

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

· evaluation of satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person’s rights as identified in section 245D.04;

· ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a, and 5;

· ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and

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

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

· designate a staff person, other than SP3, as your designated coordinator who is responsible for delivery and evaluation of services provided by the license holder;

· designate a managerial staff person, other than SP3, as your designated manager 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.

The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. Compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Submissions required as part of a corrective action ordered must be sent to your Licensor at:

1. By secure email at coty.aust@state.mn.us; or

2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below:

Commissioner, Department of Human Services

ATTN: Coty Aust

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64953

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Coty Aust, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-4605

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