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February 4, 2025 Jody Lynn Miller, Authorized Agent Lutheran Social Services of Minnesota 2485 Como Avenue Saint Paul, Minnesota 55108 Investigation Number: 202408208 Investigation Number: 202408692 Investigation Number: 202407756 License Number: 1069963 (245D – HCBS) CORRECTION ORDER Dear Jody Lynn Miller: On February 4, 2025, an investigation of Lutheran Social Services of Minnesota, located at 2485 Como Avenue, Saint Paul, 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.04, subdivision 13, paragraph (c), clause (1). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements of safekeeping of funds as required. The license holder failed to immediately document the receipt and disbursement of P1’s funds at the time of receipt or disbursement, including P1’s signature. Corrective Action Ordered: Because P1 is no longer receiving services from you, there is no corrective action required for P1. For all individuals receiving services within your program to whom you are responsible for assisting with funds and/or property, immediately upon receiving this order, you must begin documenting the receipt and disbursement of funds at the time of receipt and disbursement, including the person’s signature or the signature of the conservator or payee. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. 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 the requirements for health needs as required. a. The license holder was assigned the responsibility for meeting P1’s health needs. The license holder failed to maintain documentation on how P1’s needs will be met, including the description of procedures the license holder will follow in order to provide medication set up, assistance and administration according to this chapter. P1’s support plan addendum and information received through an interview with the license holder provided conflicting information on the procedures the license holder would follow to meet P1’s health needs and provide medication setup, assistance or administration.
b. The license holder failed to assist P1 with the coordination of medical and other health service appointments. Corrective Action Ordered: Because P1 is no longer receiving services from you, there is no corrective action required for P1. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a). Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for reviewing and reporting medication issues as required. a. For an unspecified amount of time the license holder provided medication set up and assisted P1 with self-administration of medications. The license holder failed to report concerns about P1’s ability to self-administer medications to P1’s legal representative and case manager. b. On an unknown date the license holder transitioned from providing medication setup to P1 to providing medication administration to P1. The license holder failed to report incidents as they occurred of P1’s refusal or failure to take or receive medications as prescribed. Corrective Action Ordered: Because P1 is no longer receiving services from you, there is no corrective action required for P1. 4. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For one of one person whose record was reviewed (P1), the license holder did not meet the requirements for safekeeping of funds as required. The license holder was assigned the responsibility of assisting P1 with safekeeping of funds; however the license holder failed to implement the preferences of P1, P1’s legal representative and case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds. Corrective Action Ordered: Because P1 is no longer receiving services from you, there is no corrective action required for P1. For all individuals receiving services within your program to whom you are responsible for assisting with funds and/or property, within 30 days of receiving this order, you must complete an audit of their financial records to ensure that you are surveying, documenting and implementing their preferences for receiving statements that itemize their receipt and disbursement of funds. Compliance for this citation will be reviewed at subsequent licensing reviews. 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Tammi Mitei, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6341
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