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August 7, 2026 Sapana Ghimire, Authorized Agent The Mount Everest Care LLC 112 E Welcome Avenue Mankato, Minnesota 56001 License Number: 1113272 (245D – HCBS) CORRECTION ORDER Dear Sapana Ghimire: On June 25, 2026, a licensing review of The Mount Everest Care LLC, located at 112 E Welcome Avenue, Mankato, 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 (a). Violation: For one of two persons whose records were reviewed (P1), the license holder did not provide an orientation to the program abuse prevention plan as required. The license holder did not provide P1 with an orientation to the program abuse prevention plan within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with an orientation to the program abuse prevention plan. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not inform and provide policies and procedures as required. The license holder did not inform P1’s case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation: Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the policies and procedures affecting a person’s rights to P1’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. 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 rights as required. The license holder did not provide P1 with a written notice that included the following service recipient rights when P1 resided in a residential site: · have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person; · receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; · have use of and free access to common areas in the residence; and the freedom to come and go from the residence at will; · choose the person’s visitors and time of visits and have privacy for visits with the person’s spouse, next of kin, legal counsel, religious adviser, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person’s bedroom; and · have access to three nutritionally balanced meals and nutritious snacks between meals each day. · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person’s bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; · a setting that is free from hazards that threaten the person’s health or safety; and · a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with a written notice that includes the rights identified above; · ensure all persons receiving services from you in a residential site have received a written notice that includes the rights identified above; and · maintain documentation of the person’s or the person’s legal representative’s receipt of a copy and an explanation of the rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not ensure the exercise and protection of the person’s rights in the services provided as required. a. The license holder implemented house rules that did not ensure the exercise and protection of P1’s right to: · personal privacy, including the right to use the lock on the person’s bedroom door · engage in chosen activities; · have use of and free access to common areas in the residence; and · have freedom and support to access food and potable water at any time. b. The license holder maintained documentation that staff request that P1 turn their phone in at night before bed. The license holder stated that P1 must complete a list of chores in the morning to get the phone back. The license holder did not ensure the exercise and protection of P1’s right to access to the person’s personal possessions at any time. Corrective Action Ordered: Immediately upon receiving this order, you must ensure the exercise and protection of P1’s rights. On an ongoing basis, you must ensure the exercise and protection of each person’s service recipient rights. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments as required. The license holder did not complete assessments for P1 in the following areas before providing 45 days of service or within 60 calendar days of service initiation: · 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; · 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 · the person'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 30 days of receiving this order, you must: · complete the above-mentioned assessments for P1 that produce information about the person that describes their overall strengths, skills and abilities and behaviors or symptoms; · review the results of P1’s assessments with P1and P1’s support team. You must document this review; · train all staff providing direct support services to P1 on P1’s assessments; · document this training in staff’s personnel record; · audit all person served records to ensure that assessments have been completed for all persons served receiving intensive services; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (b) and (c). Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not complete initial service planning for intensive services as required. The license holder did not hold an initial planning meeting with P1, P1’s legal representative, P1’s case manager and other members of the support team before providing 45 days of service or within 60 calendar 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 support necessary to accomplish the person’s desired outcomes; and · how technology might be used to meet the person's desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · hold a meeting with P1, P1’s case manager and other members of their support team to determine the above-mentioned information; · discuss with P1, P1’s case manager, and other members of their support team about how technology might be used to meet the person’s desired outcomes; and document a summary of this discussion in P1’s support plan addendum that includes the following: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. · audit all person served records to ensure that above has been completed for all persons served receiving intensive services; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet health service needs as required. The license holder was assigned the responsibility of meeting P1’s health service needs in P1’s support plan addendum. The license holder did not maintain documentation on how P1’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication administration; · monitor health conditions according to written instructions from a licensed health professional; and · assist with or coordinate medical, dental, and other health service appointments. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1’s support plan addendum to document the above health needs; · train all staff providing direct support services to P1 on P1’s revised support plan addendums; · document this training in each staff’s personnel record; · audit all person served records to ensure that all the above has been completed for all persons served; and · maintain documentation of the audit results. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, sections 245D.05, subdivision 2 and 245D.11, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not implement medication administration procedures as required. a. The license holder did not obtain written authorization from P1 before administering medication or treatment to P1. b. The license holder was assigned the responsibility of administering medications to P1 and P2. The license holder maintained medication lists and medication administration records (MAR) that contained conflicting information regarding dosages and frequency for several of P1’s and P2’s medications. Additionally, there was conflicting information between this documentation and the prescription labels on P1’s and P2’s medications. The license holder also administered a medication to P1 that was not transcribed on P1’s MAR. The license holder did not maintain accurate medication administration records for P1 and P2 that documented the following: · information on the prescription label or the prescriber’s current written or electronically recorded order that included the description of the medication to be provided, and the frequency and other information needed to safely and correctly administer the medication to ensure effectiveness; · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information must be readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment. c. The license holder did not implement their medication administration policy to ensure P1 and P2 took medications and treatment as prescribed when staff did not check each person’s MAR, administer medications according to the prescriber’s order, document when a medication or treatment is started, administered, changed, or discontinued, and report any concerns about the medications. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P1 to administer P1’s medication or treatment; · review P1’s and P2’s MARs from May 2026 to current to ensure the information maintained in the MAR is current and to identify medication administration errors; · report any medication errors, including if a dose of medication is not administered or treatment is not performed as prescribed, including refusals, found in P1’s and P2’s MAR to their legal representative and case manager; · develop and implement a plan to correct patterns of errors, and maintain this plan in the program’s records; and · maintain documentation of the notifications regarding the medication errors in P1’s and P2’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for psychotropic medications use and monitoring as required. P1 was prescribed multiple psychotropic medications. The license holder did not document a description of the target symptoms that each of P1’s psychotropic medications were to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must document in P1’s support plan addendum a description of the target symptoms that each psychotropic medication is prescribed to alleviate. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.06, subdivision 4, paragraph (a). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for safeguarding and handling a person’s funds and property as required. The license holder did not survey and document the preferences of P1 and P1’s case manager for the frequency of receiving a statement that itemized receipts and disbursements of P1’s funds or other property. Corrective Action Ordered: Within 30 days of receiving this order you must survey and document the above-mentioned information for P1 and P1’s case manager and implement those preferences. On an ongoing basis, you must maintain compliance as required in this subdivision 11. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: For one staff person whose record was reviewed (SP3), the license holder did not ensure the designated coordinator provided program coordination and oversight of the services provided by the license holder as required. The license holder identified SP3 as the designated coordinator. The license holder did not ensure that SP3 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. This is evident in citations 5-9. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.081, subdivision 3, paragraph (b). Violation: For one staff person whose record was reviewed (SP4), the license holder did not ensure that the designated manager met minimum position requirements. The license holder did not ensure that the staff person identified as the designated manager (SP4) minimally met the education and training requirements identified in subdivision 2, paragraph (b) and had a minimum of three years of supervisory level experience in a program that provided care or education to vulnerable adults or children. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure that an individual who meets the qualifications of designated manager according to section 245D.081, subdivision 3 assumes that role. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2). Violation: For two of four staff persons whose records were reviewed (SP1-SP2), the license holder did not maintain personnel records as required. The license holder did not maintain documentation in SP1’s and SP2’s personnel records that included the date that training was completed, and the name of the trainer or instructor for each training subject area. 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 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. Robert Romani, HCBS Licensor Licensing Division Office of Inspector General 651-431-6624
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