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December 20, 2024 Aaron Fisk Catholic Charities In Home Program 157 Roosevelt Rd. Suite 200 St. Cloud, MN 56304 License Number: 1070424/1070417 Dear Mr. Fisk: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration regarding 1 of 1 citations in the Correction Order (Attachment A) issued to you on October 2, 2024. After an independent review of the record, the Commissioner has determined that there is sufficient evidence to support the citation. Reconsideration Determination Citation 1 For one client (C), whose record was reviewed, the license holder did not implement medication administration procedures as required. The license holder was assigned the responsibility of administering the C’s medications. The license holder failed to document a notation of when a medication was administered or the reason for not administering the medication in the C’s medication administration record (MAR). Applicable Law. The license holder must ensure the following information is documented in the person’s medication administration record: … (5) notation of 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; and (6) notation of when a medication or treatment is started, administered, changed, or discontinued. Minnesota Statute § 245D.05, subdivision 2 (c) (5) and (6). Your Response. You contend that although notations were missing on the May Medication Administration Record (MAR), the missing information for May was on a separate document that was not considered by DHS. You argue that with this documentation, the record would be complete. You also argue that C was hospitalized on May 21, 2024, and that you marked an “H” on the MAR for all dates in May for which C was hospitalized. You submitted MARs for March, April, and May in support of the request for reconsideration. Reconsideration Determination. DHS reviewed MARS for March, April, and May. The April and May MARs were missing some of the notations indicating whether medications were given or refused. The May MAR documentation submitted during the investigation was incomplete because there were no notations after the morning dose for May 21st through the end of the month. The April Mar was incomplete because it did not have notations for April 2 a.m. dose, April 16 p.m. dose and April 30 a.m. and p.m. doses. The May MAR documentation you submitted on reconsideration differs from the document the licensor reviewed. The document you submitted on reconsideration has an “H” in the blank spaces from the afternoon of May 21 through the rest of the month, and however the document viewed during the investigation was blank from May 21st through the end of the month. Further, the additional document for May that you state was not considered by DHS was not provided during the investigation and was only submitted on reconsideration. The MAR with the addition of the “H” for the dates in May and the additional document will not be considered because they were not available at the time of the investigation. See Minnesota Statute, Section 245A.04, subdivision 5 (a). In your reconsideration request you had questions about the corrective action ordered. Please work with your licensor on how to comply with the corrective action. The MARS for April and May were missing notations indicating whether medications were given and or refused. This citation is affirmed. Disposition The Commissioner has reviewed the relevant laws and all of the information you submitted in response to the Correction Order. The record supports the citation, and that citation is affirmed. This is a final agency decision. If you have any questions, contact Dorothy Gause, Attorney, at 651-539-8150. Sincerely,
Kofi Montzka, Attorney Legal Counsel’s Office Office of Inspector General
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