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May 8, 2026 Pushkin Asiimwe, Authorized Agent Smart Compassionate Care LLC 5701 Shingle Creek Parkway STE 500G Brooklyn Center, Minnesota 55430 License Number: 1109726 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Pushkin Asiimwe: On March 11, 2026, a licensing review of Smart Compassionate Care LLC, located at 5701 Shingle Creek Parkway STE 500G, Brooklyn Center, 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. Violation: For two of six persons whose records were reviewed (P4 and P5), the license holder did not provide orientation to the policies and procedures related to suspected or alleged maltreatment as required. The license holder did not provide P4 and P5 with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order you must provide P4 and P5 with the orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults. You must maintain documentation of this orientation in P4’s and P5’s service recipient records. 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, P2, P5 and P6), the license holder did not develop an individual abuse prevention plan (IAPP), as required. a. The license holder initiated P1’s services on October 6, 2025. The license holder did not develop an IAPP for P1. b. The license holder initiated P2’s services on April 17, 2025. The license holder developed an IAPP for P2 on July 9, 2025. The license holder did not develop an IAPP for P2 as part of the initial individual program plan or service plan prior to or upon service initiation. c. The license holder did not review P5’s IAPP annually in 2025. d. The license holder initiated P6’s services on April 14, 2025. The license holder developed an IAPP for P6 on September 24, 2025. The license holder did not develop an IAPP for P6 as part of the initial individual program plan or service plan prior to or upon service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1 that includes an individualized assessment of the risk of abuse within the scope of the licensed service; · must document a statement of the specific measures that would be taken to minimize the risk of abuse in all areas of assessed abuse; · review P5’s IAPP with P5, P5’s legal representative and case manager; and · maintain documentation of this review in P5’s service recipient record. Compliance with this order will be reviewed onsite 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. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not provide an annual notice that identified the service recipient rights, as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder did not provide P5 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2025. b. The license holder provided P6 with a written notice that identified the service recipient rights and an explanation of those rights on January 22, 2025. The license holder provided P6 with an notice that identified the service recipient rights on March 3, 2026. The license holder did not provide P6 with an annual notice that identified the service recipient rights in 2026. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P5 with a written notice that identifies the service recipient rights and explanation of those rights. You must maintain documentation of receipt of the rights in P5’s service recipient record. Compliance with this order will be reviewed onsite 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 four of six persons whose records were reviewed (P2, P3, P4 and P6), the license holder did not provide services in response to the person’s identified needs, interests, and preferences for each service, as required. a. The license holder provided multiple services to P2. The license holder did not ensure that P2’s support plan addendum identified how services were provided for each licensed service, including how, when, and by whom. b. The license holder provided individualized home support without training services to P3. The license holder did not ensure that P3’s support plan addendum identified how services were provided for each licensed service. c. The license holder provided multiple services to P4. The license holder did not ensure that P4’s support plan addendum identified how services were provided for each licensed service d. The license holder provided employment services to P6. The license holder did not ensure that P6’s support plan addendum identified how P6’s employment services. Corrective Action Ordered: Within 30 days from receiving this order you must update P4’s support plan to identify how services will be provided for each licensed service, including how, when, and by whom. Compliance with this order will be reviewed onsite 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 three persons whose records were reviewed (P1, P2 and P3), the license holder did not develop a preliminary support plan addendum for a basic support service, as required. a. The license holder did not develop a support plan addendum for P1 within 15 calendar days of service initiation. b. The license holder initiated P2’s services on March 20, 2025. The license holder developed a preliminary support plan addendum for P2 on July 8, 2025. The license holder did not develop a preliminary support plan addendum for P2 within 15 calendar days of service initiation. c. The license holder initiated P3’s services on August 3, 2025. The license holder developed a preliminary support plan addendum for P3 on September 23, 2025. The license holder did not develop a preliminary support plan addendum for P3 within 15 calendar days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a support plan addendum for P1 that includes how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination or services. Compliance with this order will be reviewed onsite 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.071, subdivision 3, paragraphs (a) and (b). Violation: For three persons whose records were reviewed (P4, P5 and P6), the license holder did not meet initial service planning requirements for an intensive support service. a. The license holder did not complete assessments before providing 45 days of service for P4 and P5 that produced information that described P4’s and P5’s overall strengths, functional skills and abilities, and behaviors or symptoms, including: · P4’s and P5’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizure, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P4’s and P5’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · P4’s and P5’ 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 the above-mentioned assessments for P4 on December 27, 2025. b. The license holder did not meet the initial service planning requirements for P6 in the following ways: · The license holder initiated P6’s services on April 14, 2025, and developed a support plan addendum for P6 on January 14, 2026. The license holder did not develop a support plan addendum for P6 within 15 calendar days of service initiation; · The license holder did not complete assessments for P6 in the following areas before providing 45 days of service: o 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; o 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; and o the person’s ability to self-manage symptoms or behaviors 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; o assessments must produce information about the person that describes the person’s overall strengths, functional skills and abilities, and behaviors or symptoms; and · The license holder did not meet with P6, P6’s case manager and members of the support team or expanded support team within 45 days of service initiation to determine: o the scope of the services to be provided to support the person’s daily needs and activities; o the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; o 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; o whether the current service setting is the most integrated setting available and appropriate for the person; o 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; o a discussion of how technology might be used to meet the person’s desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include: · a statement regarding any decision that is made regarding the use of technology; and · a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete the required assessments for P5 and P6 that produce information about the person that describes the above-mentioned information; · meet with P6, P6’s case manager, and members of the support team to determine the above-mentioned items and to have a discussion about how technology might be used to meet P6’s desired outcomes. You must include a summary of this discussion in P6’s support plan or support plan addendum; · review the results of the assessments of P6’s ability to self-manage health and medical needs, personal safety, and symptoms or behaviors with P6, P6’s case manager, and members of the support team. You must document this review; · develop a service plan for P6 that documents the service outcomes and supports that includes the following: o the methods or actions that will be used to support P6 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 the person’s communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will 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. Compliance with this order will be reviewed onsite 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 (c). Violation: For three persons whose records were reviewed (P4, P5 and P6), the license holder did not hold an initial service planning meeting, as required. a. The license holder did not meet with P4, P5, P6, their legal representatives, case managers and members of their support teams or expanded support teams within 45 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; and · 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. The license holder held an initial service planning meeting for P5 on December 16, 2025. b. The license holder did not include P5’s case manager in P5’s initial service planning meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P4, P6, their legal representatives, case managers, members of their support teams and expanded support teams to determine the above-mentioned information; and · maintain documentation that P4’s and P6’s legal representatives and case managers were included in P4’s and P6’s initial service planning meeting. Compliance with this order will be reviewed onsite 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 4. Violation: For one person whose record was reviewed (P5), the license holder did not develop service outcomes and supports, as required. The license holder did not develop a service plan that documented the supports and methods to be implemented to support P5 to accomplish outcomes, including: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person's communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · 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 · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan for P5 that documents the service outcomes and supports based on the assessments. You must include the above-mentioned information. Compliance with this order will be reviewed onsite 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.10, subdivision 4. Violation: For six persons whose records were reviewed (P1, P2, P3, P4, P5 and P6), the license holder did not provide written or electronic copies of policies and procedures as required. a. The license holder did not provide P1 and P1’s case manager with a copy of the license holder’s emergency use of manual restraints (EUMR) policy within five working days of service initiation. b. The license holder did not provide P2 and P2’s case manager with written or electronic copies of the following policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraint policy and procedure; and · data privacy. c. The license holder did not provide P3 with a copy of the license holder’s emergency use of manual restraints policy within five working days of service initiation. Additionally, the license holder did not provide P3’s case manager with written or electronic copies of the following policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraint policy and procedure; and · data privacy. d. The license holder did not provide P4 with written or electronic copies of the following policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Additionally, the license holder did not provide P4’s case manager with written or electronic copies of the following policies and procedures: · emergency use of manual restraints policy and procedure; and · data privacy. e. The license holder did not provide P5’s case manager with a copy of the license holder’s data privacy policy and procedure within five working days of service initiation. f. The license holder did not provide P6’s case manager with written or electronic copies of the following policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraint policy and procedure; and · data privacy. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 and P1’s case manager with a copy of your emergency use of manual restraints policy and procedure. You must obtain written acknowledgement from P1’s case manager that they have been notified of this policy, and maintain this written acknowledgement in P1’s service recipient record; · provide P2 and P2’s case manager with copies of the above-mentioned policies and procedures and maintain documentation that you provided the policies and procedures. You must obtain written acknowledgement from P2 that they have been notified of your policy on the emergency use of manual restraints, and maintain this written acknowledgement in P2’s service recipient record; · provide P3 and P3’s case manager with copies of the policies and procedures mentioned above and maintain documentation that you provided the policies and procedures. You must obtain a written acknowledgement from P3 that they have been notified of your emergency use of manual restraint policy and procedure, and maintain the written acknowledgement in P3’s service recipient record; · provide P4 and P4’s case manager with copies of the policies and procedures mentioned above and maintain documentation that you provided the policies and procedures. You must obtain a written acknowledgement from P4 that they have been notified of your emergency use of manual restraint policy and procedure, and maintain a written acknowledgement in P4’s service recipient record; · provide P5’s case manager with a copy of your data privacy policy. You must maintain documentation that you provided this policy in P5’s service recipient record; and · provide P6’s case manager with copies. of the above-mentioned policies and procedures. You must maintain documentation that you provided these policies in P6’s service recipient record. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For six persons whose records were reviewed (P1 through P6), the license holder did not incorporate and evaluate positive support strategies as required. a. The license holder did not develop positive support strategies for P1 through P4, in writing to an existing treatment, service, or other individual plan. Additionally, the license holder did not evaluate the positive support strategies with P1 through P4 at least every six months. b. The license holder did not evaluate the positive support strategies with P4 and P5 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · assess P1’s through P4’s strengths, needs, and preferences to identify and create positive support strategies for each person; · incorporate the positive support strategies for P1 through P4 in writing to an existing treatment, service, or other individual plan for each person; · evaluate the established positive support strategies with P1 through P6 at least every six months; and · maintain documentation of these evaluations in P1’s through P6’s service recipient records. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide an orientation to vulnerable adult maltreatment reporting within 72 hours of first providing direct contact services, as required. a. The license holder did not provide SP3 with an orientation that combined supervised on-the-job training with review and instruction on sections 245A.66 and chapter 260E governing maltreatment reporting and service planning for children and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment within 72 hours of first providing direct contact services. b. SP4 first began providing direct contact services on March 21, 2023. The license holder provided SP4 with an orientation on vulnerable adult maltreatment reporting on August 3, 2023. The license holder did not provide SP4 with an orientation on vulnerable adult maltreatment reporting within 72 hours of first providing direct contact services. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP3 with an orientation on maltreatment of minors reporting. You must maintain documentation of this orientation in SP3’s personnel record. Compliance with this order will be reviewed onsite 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 staff persons whose record were reviewed (SP2, SP3 and SP4), the license holder did not provide orientation to the program as required. a. The license holder did not provide SP3 and SP4 with orientation that combined supervised on-the-job training with review and instruction in 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. b. SP2’s date of hire was December 20, 2024. SP4’s date of hire was March 21, 2023. The license holder did not provide SP4 orientation on the following orientation topics within 60 days of hire: · 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 and chapter 260E governing maltreatment reporting and service planning for 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; · 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. The license holder provided SP4 with orientation on the above-mentioned orientation training on August 1, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP3 and SP4 with the above-mentioned training. You must maintain documentation of this training in SP3’s and SP4’s personnel records. Compliance with this order will be reviewed onsite 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 (SP3 and SP4), the license holder did not provide and ensure orientation to individual service recipient needs as required. The license holder did not ensure SP3 and SP4 received instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and when applicable, the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans prior to SP3 and SP4 having unsupervised direct contact with a person served by the program. Corrective Action Ordered: Within 30 days of receiving this order you must provide SP3 and SP4 with training on the above-mentioned topics. You must maintain documentation of this training in SP3’s and SP4’s personnel records. Compliance with this order will be reviewed onsite 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 (SP4), the license holder did not provide annual training as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder did not provide SP4 with annual training on the following topics in 2024 and 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 and chapter 260E governing maltreatment reporting and service planning for 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; · 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; 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 30 days of receiving this order, you must provide SP4 with the above-mentioned training. You must maintain documentation of this training in SP4’s personnel record. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245C.04, subdivision 1, and section 245A.07, subdivision3, paragraph (d). Violation: For one staff person whose record was reviewed (SP4), the license holder did not maintain background study compliance as required. The license holder did not maintain an active background study for SP4. The license holder allowed SP4 to provide direct contact with persons served by the program from April 22, 2023, to January 22, 2026, without a completed background study. The license holder exercised the provisions of Minnesota Statutes, 245A.07, subdivision 3, paragraph (d), for SP4 on January 22, 2026. The license holder self-corrected SP4’s background study violation before the commissioner discovered the violation and had not exercised provisions to this paragraph in the previous 365 days. Therefore, the license holder is not fined for the background study violation for SP4. Corrective Action Ordered: Compliance with this order will be reviewed onsite 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 the designated coordinator (SP1), 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. b. The license shoulder did not ensure that the designated manager (SP1) provided 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 (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 245.04; · 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, 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. The failure to program coordination, management and oversight is evidenced in citations 1 through 11. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an audit of all participant and personnel records to ensure each person’s and each staff person’s records are in compliance with the 245D licensing requirements; · submit the following to your licensor: o the audit form you have developed; o the results of the audit; and o the date by which all participants and personnel records will be in compliance with the 245D licensing requirements. This date must be before July 8, 2026. Compliance with this order will be reviewed onsite 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 Kate Spenger; 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: Kate Spenger 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. Kate Spenger, HCBS Licensor Licensing Division Office of Inspector General 651-431-5757
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