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March 25, 2024 Renae Sternke, Authorized Agent Catholic Charities In Home Program 911 Eighteenth Street North Saint Cloud, Minnesota 56303-1203 License Number: 1070417 (245D – HCBS) CRS License Number: 1070421 Investigation Report Number: 202309285 CORRECTION ORDER Dear Renae Sternke: On February 16, 2024, a licensing investigation of Catholic Charities In Home Program, located at 13 Eight Avenue South, Cold Spring, 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 investigation. 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 245D.05, subdivision 1. Violation: For one of one person whose record was reviewed (P1), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was responsible for meeting P1’s health service needs in the support plan. The license holder was responsible for administering oxygen and checking oxygen saturations. The license holder failed to maintain documentation with a description of the procedures the license holder will follow in order to monitor health conditions and use medical equipment safely and correctly according to written instructions from a license licensed health professional. P1 is no longer receiving services from the license holder. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for medication and treatment administration as required. The license holder was responsible for the administration of P1’s medications and treatments in P1’s support plan. The license holder failed to administer medications and treatments according to the license holder’s medication administration policy and procedures as required under section 245D.11, subdivision 2, clause (3). · The license holder failed to document a notation in P1’s medication administration record of the administration of any of P1’s prescribed medications for October 31, 2023. · The license holder failed to include a description of the treatments to be provided, the frequency, and other information needed to administer treatments safely and correctly in P1’s medication administration record. It is unknown if the treatments were performed as prescribed. · P1’s medication administration record documented a medication that was to be administered for 10 days, starting October 3, 2023. The license holder failed to document the end date of the medication cycle resulting in the administration of this medication that exceeded the 10 days. · The license holder administered multiple PRN medications throughout the month of October 2023. The license holder failed to maintain documentation with a notation of the time the PRN medications were administered. Corrective Action Ordered: Within 30 days of receiving this order, you must; · provide training to all direct support staff that administer medications at this program on the license holder’s medication administration policy and the requirements in Minnesota Statues, 245D.05, subdivision 2; and · the identified designated manager(s) must ensure after completion of the above mentioned training, that all staff are competent in the implementation of the license holder’s medication administration policy. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.06, subdivision 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for protection standards as required. “Chemical restraint” means the administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and it not a standard treatment or dosage for the person’s medical or psychological condition. The license holder maintained a protocol in P1’s record with documentation of the description of the procedures the license holder would follow in order to safely administer P1’s PRN medication for sleep. The protocol documented that staff could offer PRN Trazodone if P1 was not asleep by 9:00pm. The license holder administered PRN Trazodone to P1 on October 31, 2023, prior to 6:50 pm, as a behavior intervention. The license holder used a prohibited procedure in the form of a chemical restraint when the PRN was administered for behavior intervention and not its intended use. Corrective Action Ordered: Immediately, upon receiving this order, you must report the use of the PRN medication to intervene in a behavioral situation on the behavior intervention reporting form required by the commissioner. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not maintain the service recipient record as required. The license holder failed to maintain progress or daily log notes that are recorded by the program for October 31, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 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 Amber Nielsen at amber.n.nielsen@state.mn.us or 651-431-3661 as soon as possible. Amber Nielsen, Senior Human Services Licensor Licensing Division Office of Inspector General
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