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March 24, 2025 Christine Paisley Claiborne, Authorized Agent C & H Services MN LLC 570 Asbury Street, Suite 106B Saint Paul, Minnesota 55104 License Number: 1111628 (245D – HCBS) CORRECTION ORDER Dear Christine Paisley Claiborne: On February 20, 2025, and February 21, 2025, a licensing review of C & H Services MN LLC located at 570 Asbury Street, Suite 106B, 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.65, subdivision 2. Violation: For two of three persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for abuse prevention plans as required. a. P2’s night supervision services were initiated on August 23, 2024. The license holder failed to develop an individual abuse prevention plan (IAPP) as part of P2’s initial individual program plan or service plan prior to or upon service initiation. b. P2’s individualized home supports with training services were initiated on August 14, 2023. The license holder assessed P2 to be susceptible to abuse. The license holder failed to include a statement of the specific measures that would be taken to minimize the risk of abuse. c. The license holder failed to establish a program abuse prevention plan (PAPP) for community residential setting (CRS: 1123924) where P1 resided, that assessed the population currently served at the CRS, including an evaluation of the following factors: · age; · gender; · mental functioning; · physical and emotional health or behavior of the client; · the need for specialized programs of care for the client; · the need for training of staff to meet identified individual needs; and · the knowledge a license holder may have regarding previous abuse that is relevant to minimizing the risk of abuse for the client. Corrective Action Ordered: Within 30 days of receiving this order you must: · develop an IAPP for P2 that includes an individualized assessment of P2’s susceptibility to abuse by other individuals, P2’s risk of abusing others, and statements of the specific measures that will be taken to minimize the risk of abuse; · review P2’s IAPP with P2, P2’s case manager and other members of the support team. You must maintain documentation of the review in P2’s record; · you must evaluate the factors mentioned above and revise the PAPP; and · provide orientation to the revised PAPP to all staff persons that provide services at that CRS and persons served that receive services at that CRS. You must maintain documentation of when the orientation was provided in person served and staff records. 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 (P2), the license holder did not provide written notice that identified the service recipient rights as required. The license holder failed to provide P2 with written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights within five working days of service initiation and annually thereafter. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2 with written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights. You must maintain documentation receipt of a copy and explanation of the rights in P2’s record. 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 (P2), the license holder did not meet health service needs as required. The license holder was assigned responsibility for meeting P2’s health needs P2’s support plan. The license holder failed to maintain documentation on how P2’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication set up, assistance, or administration according to this chapter; · monitor health conditions according to written instructions from a licensed health professional; and · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation on how P2’s health needs will be met, including a description of the procedures the license holder will follow in order to meet P2’s health service needs. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not implement medication administration procedures as required. a. The license holder failed to obtain written authorization from P2 to administer P2’s medications and treatments prior to the license holder administering medications and treatments. b. The license holder was assigned responsibility for administration of medication and treatments for P2. The license holder failed to maintain a medication administration record (MAR) for P2 that included the following information: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information (risks, side effects, and contraindications) was readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment; · 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 · notation of when a medication or treatment was started, administered, changed, or discontinued. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a medication administration record for P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. a. The license holder was assigned responsibility for administering P1’s psychotropic medications. The license holder failed to: · maintain a description of the target symptoms that each psychotropic medication was to alleviate; · develop documentation methods that would be used to monitor and measure changes in the target symptoms as required by the prescriber; and · provide the monitoring data to the expanded support team for review every three months. b. The license holder was assigned responsibility for administering P3’s psychotropic medications. The license holder failed to maintain a description of the target symptoms that each psychotropic medication was to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must develop, implement, and maintain documentation regarding psychotropic medications. On an ongoing basis, you must provide the monitoring data to the expanded support team as required. 6. Citation: Minnesota Statutes, 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P1), the license holder did not provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as required. The license holder failed to provide services in a manner that supported P1's accomplishment of personal goals and service outcomes, consistent with the principles of person-centered service planning and delivery. The following service outcomes for P1 were initiated July 1, 2024: · P1 had an outcome to ride his bike once per month. At the time of the licensing review, P1 had not been supported with this outcome, and had not ridden his bike. · P1 had an outcome to go swimming. At the time of the licensing review, P1 had not been supported with this outcome, and had not gone swimming. · P1 had an outcome to access the community three times per week. Outcome data records revealed P1 had not been taken into the community at all in December 2024, and only once in January 2025. Corrective Action Ordered: Immediately, upon receiving this order you must begin providing services in response to the person’s identified needs, interests, preferences, and desired outcomes consistent with the principles of person-centered service planning and delivery. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for basic services as required. The license holder failed to review and revise P2’s preliminary support plan addendum to document the night supervision services that would be provided including how, when and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services within 60 calendar days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s preliminary support plan addendum to document the night supervision services that will be provided including how, when and by whom services would be provided, and the person responsible for overseeing the delivery and coordination. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not complete assessments and initial service planning as required. a. The license holder failed to complete an assessment for P1 that: · accurately assessed the person’s ability to self-manage symptoms or behavior that may otherwise result in an incident, suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others; and · included information about the person that describes the person’s overall strengths, as well as functional skills and abilities. b. The license holder failed to have a discussion of how technology might be used to meet P1’s desired outcomes P1’s initial service planning meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1’s assessments to accurately assess P1’s ability to self-manage symptoms or behavior that may otherwise result in an incident, suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others; · review and revise P1’s assessments to ensure the assessments include information about the person that describes the person’s overall strengths, as well as functional skills and abilities; · have a discussion with P1’s support team about how technology could be used to meet P1’s desired outcomes. The support plan addendum must include: o a summary of this discussion; o summary must include a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. 9. Citation: Minnesota Statutes, 245D.071, subdivision 4 Violation: For one person whose record was reviewed (P1), the license holder did not document the supports and methods to be implemented to support the person and accomplish their outcomes as required. The license holder failed to include the methods or actions that would be used to support P1 to accomplish their service outcomes, including information about: · any changes or modifications to the physical and social environments necessary when the service supports are provided; · any equipment and materials required; and · the measurable and observable criteria for identifying when the desired outcome has been achieved. Corrective Action Ordered: Within 30 days of receiving this order, you must revise P1’s outcomes to include the above mentioned methods or actions that will be used to support P1 to accomplish their service outcomes. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.95, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not maintain service recipient record as required. a. The license holder failed to maintain daily log notes or progress notes that are recorded by the program. b. The license holder failed to maintain documentation of P2’s current orders for medications, treatments, or medical equipment. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation of P2’s current orders for medications, treatments, or medical equipment. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not provide written or electronic copies of policies and procedures as required The license holder failed to inform P2 and P2’s case manager of the policies and procedures affecting P2’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: • grievance policy; • temporary service suspension policy; and • service termination policy. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2 and P2’s case manager with written or electronic copies of the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. a. The license holder failed to incorporate positive support strategies to P1’s existing treatment, service, or other individual plan required of the license holder. · On October 29, 2024, the license holder held a team meeting for P1 and indicated that reinforcers, verbal praise, prompting, and first this/then this language was being utilized as positive support strategies; however, the license holder failed to incorporate the identified positive support strategies for P1 in writing to P1’s existing treatment, service, or other individual plans. b. The license holder failed to evaluate the identified positive support strategies with P2 every 6 months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · incorporate the identified positive support strategies for P1 in writing to P1’s existing treatment, service, or other individual plans; and · evaluate the identified positive support strategies with P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Violation: For one person whose record was reviewed (P2), the license holder did not provide notice of the emergency use of manual restraints policy as required. The license holder failed to provide P2 with notice and obtain a written acknowledgement of the license holders policy on emergency use of manual restraints at the time of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2 with notice and obtain a written acknowledgement of the license holders policy on emergency use of manual restraints. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three of four staff persons whose records were reviewed (SP2, SP3, and SP4), the license holder did not provide orientation to policies and procedures as required. The license holder failed to provide SP2, SP3 and SP4 with orientation to the license holder's policy and procedure on health service coordination and care as required under Minnesota Statutes, chapter 245D, including their location and access, and staff responsibilities related to implementation of that policy and procedure. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2, SP3 and SP4 with orientation to the license holder's policy and procedure on health service coordination and care. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required. a. The license holder failed to provide SP1 with instruction on the safe and correct operation of medical equipment used by P2 to sustain life or to monitor a medical condition that could become life-threatening without proper use of the medical equipment, including but not limited to ventilators, feeding tubes, or endotracheal tubes. b. The license holder failed to orientate SP2 on P1's support plan or support plan addendum as it relates to the responsibilities assigned to the license holder. P1 had a seizure protocol however, there was no evidence within SP2’s staff record of orientation to P1’s protocols. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an audit of all staff that work with SP1 and SP2; · train all staff on the above-mentioned topics (as applicable); · maintain documentation of these trainings in the staff’s personnel file. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training as required. Minnesota Statutes, 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent year. a. The license holder failed to provide SP1 with annual training as required in the following areas: · 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. This training was provided on September 10, 2024; · 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. This training was provided on September 9, 2024; · 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 245A.65, subdivision 3. This training was provided on September 10, 2024; · 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. This training was provided on September 10, 2024; · 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. This training was provided on September 10, 2024; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. This training was provided on September 10, 2024, and December 2, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must train SP1 on the safe and correct use of manual restraint on an emergency basis, and staff responsibilities related to prohibited procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For four staff persons whose records were reviewed (SP1, SP2, SP3, and SP4), the license holder did not maintain personnel records as required. For SP1, SP2, SP3, and SP4, the license holder failed to maintain the hours of training per subject area and the name of the instructor in the personnel records. 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. 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 at 651-431-3661 as soon as possible. Amber Nielsen, Home and Community-Based Services Licensor Licensing Division Office of Inspector General
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