Minnesota

June 23, 2026

Pamela Arrey, Authorized Agent

Zion Care Services LLC

2233 North Hamline Avenue, Suite 127

Roseville, Minnesota 55113

License Number: 1103012 (245D – HCBS)

Investigation Report Number: 202603638

CORRECTION ORDER

Dear Pamela Arrey:

On June 17, 2026, a licensing review of Zion Care Services LLC, located at 2233 North Hamline Avenue, Suite 127

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 2.

Violation: For two of three persons whose records were reviewed (P1 and P2), the license holder did not develop and review the individual abuse prevention plan (IAPP) as required.

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 review and evaluate P1’s IAPP annually in May 2026.

b. The license holder did not develop an IAPP upon service initiation for P2.

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

· establish and enforce an IAPP for P2 that meets the requirements of this section;

· review P1’s and P2’s IAPP with the person, their legal representative, if applicable, and their case manager;

· maintain documentation of this review in P1’s and P2’s record;

· audit all service recipient records to ensure IAPPs have been developed, reviewed and evaluated; and

· maintain documentation of the audit results at your program for review by DHS licensors.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide the service recipient rights as required.

The license holder did not provide P1, P2, or P2’s legal representative with a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation and annually thereafter. The license holder initiated P1’s services on May 20, 2025, and initiated P2’s services on March 4, 2021.

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

· provide P1, P2 or P2’s legal representative with an explanation and written notice that identifies the service recipient rights in subdivisions 2 and 3;

· audit all service recipient records to ensure they have received an explanation and written notice that identifies the service recipient rights in subdivisions 2 and 3; and

· if any service recipient has not received these rights, or has not received these rights in the last annual year, provide these rights to the person or their legal representative, if applicable;

· maintain documentation of the person or their legal representative’s receipt of these rights as required in Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b); and

· maintain documentation of the audit results at your program for review by DHS licensors.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide services that complied with the requirements of this chapter and the federal waiver plans.

a. The license holder did not provide services to P1 that complied with the requirements of this chapter and the federal waiver plans, as required. The license holder initiated P1’s services on May 20, 2025. The license holder did not complete required service initiation documentation for P1 and did not maintain a support plan addendum for P1 until June 15, 2026.

b. The license holder did not provide services to P2 that complied with the requirements of this chapter and the federal waiver plans, as required. The license holder initiated P2’s services on March 4, 2021. The license holder did not complete required service initiation documentation for P2 and did not maintain a support plan addendum since P2 began receiving services in 2021.

Corrective Action Ordered: Concerns regarding the license holder’s service planning documentation and billing for home and community-based services were referred to the Department of Human Services, Office of Inspector General, Program Integrity and Oversight Division. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For one person whose record was reviewed (P1), the license holder did not provide person-centered planning and service delivery.

The license holder did not provide services in response to P1’s preferences, daily needs, and activities and accomplishment of P1’s personal goals and service outcomes, consistent with the principles of:

· person-centered service planning and delivery that:

o identified and supported what was important to P1 as well as what is important for P1, including preferences for when, how, and by whom direct support service is provided;

· self-determination that supported and provided:

o opportunities for the development and exercise of functional and age-appropriate skills, decision making and choice, personal advocacy, and communication; and

o the affirmation and protection of P1’s civil and legal rights;

· providing the most integrated setting and inclusive service delivery that supports, promotes, and allows:

o inclusion and participation in P1’s community as desired by P1 in a manner that enabled P1 to interact with nondisabled persons to the fullest extent possible and supports the person in developing and maintaining a role as a valued community member;

o opportunities for self-sufficiency as well as developing and maintaining social relationships and natural supports; and

o a balance between risk and opportunity, meaning the least restrictive supports or interventions necessary are provided in the most integrated settings in the most inclusive manner possible to support the person to engage in activities of P1’s own choosing that may otherwise present a risk to P1’s health, safety, or rights.

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

· audit all current service recipient records to ensure person-centered service planning and delivery;

· review and revise, as needed, current service recipient support plan addendums to ensure compliance with the requirements of this subdivision; and

· maintain documentation of the audit results at your program for review by DHS licensors.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

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

The license holder did not complete a preliminary support plan addendum to document services that will be provided within 15 days of service initiation dated May 20, 2025 for P1 and March 4, 2021 for P2. This was completed for P1 on June 15, 2026.

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

· review and revise, as needed, P1’s and P2’s support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of those services;

· audit all service recipient records receiving basic support services to ensure a 60-day review was completed for each basic support service provided and the required information identified in this citation are documented in the person’s support plan addendum;

· for any service in which a 60-day review was not completed and/or the information identified in this citation is not documented in the person’s support plan addendum, complete the review and document the requirements identified above; and

· maintain documentation of the audit results at your program for review by DHS licensors.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.095, subdivision 2.

Violation: The license holder did not maintain an admission and discharge register as required.

The license holder did not keep a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder and deaths.

Corrective Action Ordered: Within 60 days of receiving this order, you must complete and maintain a register of the persons served in your program as identified above. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain a service recipient record as required.

The license holder did not maintain progress or daily log notes that were recorded by the program for P1 and P2 as required.

Corrective Action Ordered: Concerns regarding the provider’s progress or daily log notes and billing for home and community-based services were referred to the Department of Human Services, Office of Inspector General, Program Integrity and Oversight Division. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statutes, section 245D.10, subdivision 3a.

Violation: For one person whose record was reviewed (P3), the license holder did not enforce policies and procedures related to service termination as required.

The license holder issued a notice of service termination to P3 on November 10, 2023. The license holder did not enforce their service termination policy when they did not document the following:

· consultation with the person’s support team or expanded support team to identify and resolve issues leading to issuance of the termination notice;

· a request to the case manager for intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support the person in the program; and

· the following information in the notice of termination:

o the reason for the action; and

o a summary of actions taken to minimize or eliminate the need for service termination or temporary service suspension as required under paragraph (c), and why these measures failed to prevent the termination or suspension.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Rule 9544.0030, subpart 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required.

The license holder did not incorporate, in writing, positive support strategies to an existing treatment, service, or other individual plans for P1 and P2. Additionally, the license holder did not evaluate these strategies with P1 and P2 at least every six months.

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

· incorporate, in writing, positive support strategies to an existing treatment, service, or other individual plan for P1 and P2;

· audit all service recipient records to ensure positive support strategies are incorporated, in writing, to an existing treatment, service, or other individual plan;

· for any service recipient record in which positive support strategies have not been incorporated, in writing, develop and incorporate these and maintain this documentation in the person’s support plan addendum; and

· maintain documentation of the audit results at your program for review by DHS licensors.

Additionally, you must evaluate these strategies with each service recipient at least every six months. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subpart.

10. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For one of three staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required.

The license holder did not provide the following trainings within 60 days of hire on June 16, 2023:

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

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

o following safety practices established by the license holder as required in section 246D.06, subdivision 2;

· the license holder’s current policies and procedures required under Minnesota Statutes, chapter 245D, including their location, 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 (HIPPA), 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 Minnesota Statutes, section 245D.04;

· sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 265A.65, subdivision 3;

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

· the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061, and what constitutes the use of restraints, time out, and seclusion including chemical restraints;

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe;

· basic first aid; and

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

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

· audit all current personnel records to ensure that all orientation training has been provided as required in this subdivision;

· provide any required orientation to all staff persons providing direct care services; and

· maintain the audit results at your program for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to individual service recipient needs as required.

The license holder did not provide SP2 with orientation to individual service recipient needs prior to SP2 having direct contact with persons served by the program.

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

· audit all current personnel records to ensure that each staff person has received orientation to the individual service recipient needs of each service recipient that staff person provides direct support services to;

· provide any required individual service recipient needs orientation for staff providing direct support services; and

· maintain the audit results at your program for review by DHS licensors.

On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

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

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 SP1 with annual training in 2024, 2025, and 2026 on the following topics identified in subdivision 4, clauses (3) to (11) as required:

· 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;

· 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 SP2 with annual training in 2024, 2025, and 2026 on the following topics identified in subdivision 4, clauses (3) to (11) as required:

· 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; SP2 completed this training on May 13, 2026;

· 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 SP3 with annual training on the following topics prior identified in subdivision 4, clauses (3) to (11) as required:

· data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices in 2023 and 2024. This was last provided in May 2026;

· 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 in 2023-2025. This was last provided in May 2026;

· the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support services provided by the staff person in 2023-2025. This was last provided in May 2026;

· basic first aid in 2023-2026; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities in 2023-2026.

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

· provide SP1-SP3 training on the topics identified above;

· complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter;

· provide any lapsed training identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and

· maintain documentation of the audit results at your program for review by DHS licensors.

Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

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

The license holder did not maintain documentation in SP1-SP3’s personnel record or elsewhere, sufficient to determine the date of first supervised direct contact with a person served by the program, and the date of first unsupervised contact with a person served by the program.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: The license holder did not establish and maintain policies and procedures related to the internal reporting of alleged or suspected maltreatment.

The license holder did not maintain a maltreatment of vulnerable adults reporting and internal review policy that identified the secondary person or position responsible when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment.

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

· establish and implement the above-stated policy to be in compliance with statutory requirements; and

· provide the updated policies and procedures to all persons served, their legal representatives (if applicable) and their case manager.

Compliance with this order will be monitored onsite. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter.

15. Citation: Minnesota Statutes, section 245A.66, subdivision 1.

Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of minors as required.

The license holder did not identify the primary and secondary person or position to whom internal reports may be made and the primary and secondary person or position responsible when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment.

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

· establish and implement the above-stated policy to be in compliance with statutory requirements; and

· provide the updated policies and procedures to all persons served, their legal representatives (if applicable) and their case manager.

Compliance with this order will be monitored onsite. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter.

16. Citation: Minnesota Statutes, section 245D.10, subdivision 3 and 3a.

Violation: The license holder did not establish written policies and procedures related to service suspension and service termination as required.

The license holder did not establish policies and procedures for service suspension and service termination that promote continuity of care and service coordination with the person and the case manager and with other licensed caregivers, if any, who also provide support to the person.

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

· establish and implement the above-stated policy to be in compliance with statutory requirements; and

· provide the updated policies and procedures to all persons served, their legal representatives (if applicable) and their case manager.

Compliance with this order will be monitored onsite. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter.

17. Citation: Minnesota Statutes, section 245D.081, subdivision 2 and 3.

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

a. The license holder did not ensure the designated coordinator (SP1), provided supervision, support, and evaluation of activities that include:

· oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service 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 coordinated service and 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.

b. The license holder did not ensure that the designated manager (SP1) 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 section 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, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a and 5; and

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

See citations 1 through 16 for the designated coordinator and designated manager’s failures to provide the above stated requirements.

Corrective Action Ordered: Within 30 days of receiving this order, you must designate a staff person who is responsible for delivery and evaluation of services provided by the license holder. You must also designate a managerial staff person to provide program management and oversight of the services provided by the license holder. The same person may perform both functions if the work and education requirements are met in section 245D.081, subdivisions 2 and 3. You must submit the name(s) and qualifications of the staff person or staff persons who will act as the designated coordinator and designated manager to your licensor.

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 kelly.bosch@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: Kelly Bosch

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

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

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

Kelly Bosch, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-6621

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