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December 21, 2022 Stephen Pareja, Authorized Agent 157 Roosevelt Road Suite 200 Saint Cloud, MN 56301 RE: Report No. 202204475 Catholic Charities CAHI Home License No. 1070425/1070417 Dear Mr. Pareja: CORRECTION ORDER An investigation of Catholic Charities CAHI Home was completed regarding report number 202204475 which alleged violation of Minnesota Statutes, section 626.557, and Minnesota Statutes, Chapter 245D. This maltreatment allegation concerned physical abuse and neglect. The disposition of the investigation report is inconclusive. Two violations were noted. VIOLATIONS AND CORRECTION ORDERS The following violations of state and (or) federal laws and rules were observed. Corrective action for each violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07. 1. Citation: Minnesota statutes, section 245D.07, subdivision 1. Violation: The license holder must provide services as assigned in the coordinated service and support plan addendum (CSSPA). A facility resident’s (R1’s) CSSPA stated that s/he had “two overnight staff [persons] on site and during the day for transferring and changing [him/her] as needed.” Facility information showed that on numerous days there was only one staff person working at the facility during the day and evening, and routinely there was only one staff person scheduled to work overnight. Corrective Action Ordered: Within 30 days of receiving this report, and on a continuing basis, you must provide services as assigned in the person’s support plan as required under this subdivision. 2. Citation: Minnesota Statutes, section 245D.05 subdivisions 2 and 4. Violation: The license holder must implement medication administration procedures to ensure a person receives medications and treatments as prescribed and that medication administration records are reviewed as required. a. The license holder was assigned the responsibility for meeting a facility resident’s (R2’s) health services needs including the administration of medication and treatments. Documentation showed R2 was seen at a wound care clinic twice per month for at least six months. Physician orders for dressing changes and topical medications were changed monthly; however, the medication administration record (MAR) for R2 was never updated to include how many times per day the dressing was supposed to be changed or the topical medications that were ordered. b. Staff persons failed to document completion of R2’s wound care on 38 days over a six month period. At least two staff persons told this investigator that documentation of the wound care was not needed. c. Documentation from a facility health care professional also showed s/he reviewed the MARs monthly and did not identify any errors or address the care not initialed as being completed. Each page of the MARs did not include the month or year. Corrective Action Ordered: Within 30 days of receiving this report, and on a continuing basis, you must: · implement medication administration procedures to ensure a person takes medications and treatments as prescribed; · document when a medication or treatment is started, administered, changed, or discontinued; and · document any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made. Additionally, if you are assigned responsibility for medication administration, you must ensure that the information maintained in the MAR is current and is regularly reviewed to identify medication administration errors. At a minimum, the review must be conducted every three months, or more frequently as directed in the support plan or support plan addendum or as requested by the person or the person's legal representative. Based on the review, you must develop and implement a plan to correct patterns of medication administration errors when identified. If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to: Commissioner Minnesota Department of Human Services c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order. If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, . Sincerely,
Deb Neubauer-Hoffman, Investigator Office of Inspector General Licensing Division deb.neubauer-hoffman@state.mn.us 651-431-6567 Enclosure
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