Minnesota

September 24, 2026

Pamela Arrey, Authorized Agent

Zion Care Services LLC

2233 North Hamline Avenue, Suite 127

Roseville, Minnesota 55113

License Number: 1103012 (245D – HCBS)

CORRECTION ORDER

Dear Pamela Arrey:

On September 23, 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 two 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 developed an IAPP for P1 and P3 that identified they were not susceptible to any area of abuse, which was inconsistent with other information maintained in their record.

b. The license holder did not review P1 and P3’s IAPP with P1 and P3’s interdisciplinary team at least annually.

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

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

· establish and enforce an IAPP for P1 and P3 that meets the requirements of this section;

· review P1 and P3’s IAPP with P1, P3, P1 and P3’s case manager;

· maintain documentation of this review in P1 and P3’s service recipient record; and

· submit the documentation to your licensor.

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 the service recipient rights as required.

The license holder did not provide P1 with a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation on November 1, 2025.

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

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

· provide P1 with an explanation and written notice that identifies the service recipient rights in subdivisions 2 and 3; and

· submit the documentation to your DHS licensor.

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

3. Citation: Minnesota Statutes, section 245D.05, subdivision 1.

Violation: For one person whose record was reviewed (P1), the license holder did not meet health service needs as required.

The license holder did not maintain documentation of how P1’s health needs would be met, including a description of the procedures the license holder would follow to provide medication assistance with documented responsibility.

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

· update P1’s support plan addendum to document a description of the procedures the license holder will follow to provide medication assistance to P1; and

· audit all current service recipient records to ensure that areas of health service needs are consistent across each record and documented accurately according to this section.

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

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

Violation: For one person whose record was reviewed (P3) the license holder did not inform and provide policies and procedures to the case manager as required.

The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P3’s case manager within five working days of basic support service initiation on July 13, 2026:

· grievance policy and procedure;

· service suspension policy and procedure;

· service termination policy and procedure; and

· emergency use of manual restraints policy and procedure.

This was completed on September 22, 2026.

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

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

Violation: For two of three staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation training as required.

a. The license holder did not provide SP2 with the following required orientation trainings within 60 days of hire on October 1, 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.

b. The license holder did not provide SP3 with the following required orientation trainings within 60 days of hire on July 15, 2026:

· 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 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;

· 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.

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 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

· submit the audit results to your licensor.

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

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

Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation to individual service recipient needs as required.

The license holder did not provide SP2 and SP3 with orientation to individual service recipient needs prior to SP2 and SP3 having direct contact with persons served by the program.

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

Corrective Action Ordered: Within 30 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

· submit the audit results to your licensor.

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

7. 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.

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 and 2025 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.

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

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

· provide SP1 and SP2 with training on the topics identified above;

· complete an audit of all staff records to ensure all required annual 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

· submit the audit results to your licensor.

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

8. Citation: Minnesota Statutes, section 245D.081, subdivisions 1 and 3.

Violation: The license holder did not provide program management and oversight of the services provided as required.

The license holder did not ensure that corrective action was taken when ordered by the commissioner. The commissioner issued a correction order to the license holder on June 23, 2026. The license holder was ordered to take corrective action for 13 citations. The license holder did not complete corrective action for 6 of the 13 violations

Repeat Violation: In a Correction Order that DHS issued on June 23, 2026, you were previously found in violation of this same statute.

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.

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/