|
June 30, 2026 Zayna Shire, Authorized Agent Complete Care Home Care 4141 Central Avenue Northeast, Suite 202 Columbia Heights, Minnesota 55421 License Number: 1099682 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Zayna Shire: On April 15, 2026, a licensing review of Complete Care Home Care, located at 4141 Central Avenue Northeast, Columbia Heights, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two of three persons whose records were reviewed (P1 and P3), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder initiated individualized home supports with training services for P1 on September 19, 2025. The license holder did not develop an IAPP as part of the initial individual service plan prior to or upon service initiation. The license holder developed the IAPP on March 1, 2026. b. The license holder did not develop an accurate IAPP for P3. The license holder maintained an IAPP for P3 that indicated P3 had no vulnerabilities to physical abuse. This was not consistent with information documented elsewhere in P3’s plan. Corrective Action Ordered: Within 30 days of receiving this order you must: · revise the IAPP for P3 to include the information that meets the requirements of this section; · review the revised IAPP with P3 and their case manager; · provide orientation to staff on the revised IAPP for P3; and · maintain documentation of this orientation in personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide a written notice that identified the service recipient’s rights as required. The license holder initiated individualized home supports with training for P1 on September 19, 2025. The license holder did not provide a written notice to P1 that identified the service recipient rights and an explanation of those rights within five working days of service initiation. The license holder provided this notice to P1 on March 1, 2026. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraphs (b) and (c). Violation: For one person whose record was reviewed (P1), the license holder did not complete and review the preliminary support plan addendum for basic support services as required. a. The license holder initiated individualized home supports without training services for P1 on March 1, 2023. The license holder did not review and revise P1’s support plan addendum to document the services that would be provided including how, when, and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services within 60 calendar days of initiating P1’s services. b. The license holder initiated night supervision services for P1 on March 1, 2024. The license holder did not complete a preliminary support plan addendum based on the support plan within 15 calendar days of initiation P1’s night supervision services. This was developed on March 10, 2026. c. The license holder did not review and revise P1’s support plan addendum to document the services that would be provided including how, when, and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services within 60 calendar days of initiating P1’s night supervision services. d. The license holder initiated individualized home supports with training services for P1 on September 19, 2025. The license holder did not complete a preliminary support plan addendum based on the support plan within 15 calendar days of initiation P1’s individual support with training services. This was developed on March 10, 2026. e. The license holder did not review and revise P1’s support plan addendum to document the services that would be provided including how, when, and by whom services will be provided and the person responsible for overseeing the delivery and coordination of services within 60 calendar days of initiating P1’s individualized home supports with training services. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P1’s support plan addendum to document how, when, and by whom P1’s night supervision and individualized home supports with training services will be provided and the person responsible for overseeing the delivery and coordination of services. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivisions 2 and 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet service planning requirements for basic support services as required. a. P1’s support plan addendum assigned the license holder to participate in service planning and support team meetings for P1 annually. The license holder did not participate in a meeting for P1 in 2024. b. P1’s and P2’s support plan addendum assigned the license holder to provide written reports to P1’s and P2’s support team regarding progress or status annually. The license holder did not provide written reports to P1’s support team annually in 2024 and did not provide P2’s support team with written reports annually in 2024 and 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P3), the license holder did not develop a service plan that documents the service outcomes and supports as required. The license holder did not document the following supports and methods to accomplish service outcomes for P3: · the methods or actions that will be used to support the person and 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 update P3’s service outcomes and supports with the information listed above. You must provide training to staff on the revised information. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. 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 documentation as required. The license holder did not maintain progress or daily log notes for P1. Corrective Action Ordered: Within 30 days of receiving this order, you must begin recording and maintaining progress or daily log notes for P1. Concerns regarding the provider’s daily log notes and billing for home and community based services were referred to the Department of Human Services, Officer of Inspector General, Program Integrity and Oversight Division. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not inform and provide copies of the policies and procedures affecting a person’s rights as required. a. The license holder initiated individualized home supports without training services for P1 on March 1, 2023. The license holder initiated integrated community supports for P3 on August 29, 2025. The license holder did not inform and provide P1’s and P3’s case manager of the following policies and procedures withing five working days of service initiation: · grievance; · service suspension and termination; and · emergency use of manual restraints. The license holder provided these policies and procedures to P1’s case manager on February 15, 2024. The license holder provided these policies and procedures to P3’s case manager on October 5, 2025. b. The license holder initiated individualized home supports with training services for P1 on September 19, 2025. The license holder did not inform and provide P1 and P1’s case manager of the following policies and procedures withing five working days of service initiation: · grievance; · service suspension and termination; and · emergency use of manual restraints. The license holder provided these policies and procedures to P1 on March 1, 2026. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did evaluate positive support strategies as required. The license holder did not evaluate P1’s and P2’s identified positive support strategies with P1 and P2 at least every six months. The license holder evaluated positive support strategies with P2 in March 2026. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P1 their identified positive support strategies. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review of maltreatment reporting, 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 SP1 with an annual review of maltreatment reporting in 2025. b. The license holder did not provide SP2 with an annual review of maltreatment reporting in 2023, 2024 and 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. The license holder did not provide SP1 with an orientation on the person’s coordinated service support plan or coordinated service support plan addendum as it relates to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve an understanding of the person as a unique individual and how to implement those plans. b. The license holder did not provide SP2 with instruction on P2’s medication assistance as assigned in P2’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with orientation training on the above-mentioned topics. You must maintain documentation of this training in SP1’s and SP2’s personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), 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. a. The license holder did not provide SP1 with annual training on the following topics in 2025: · 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; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person=; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder provided the above trainings to SP1 on May 11, 2024 and August 7, 2025. b. The license holder did not provide SP2 with annual training on the following topics: · 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 in 2023 and 2024. SP2 most recently received this training on August 26, 2025; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities in 2023 and 2024. SP2 most recently received this training on August 26, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 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. Jenna Johnson, HCBS Licensor Licensing Division Office of Inspector General 651-431-2804
|
