Minnesota

April 7, 2025

Kayla Peltier, Authorized Agent

Beacon Specialized Living Minnesota Inc

1355 Mendota Heights Road Suite 260

Mendota Heights, Minnesota 55120-1168

License Number: 1070450 (245D – Home and Community- Based Services)

1119095 (Home and Community- Based Services - Child Corporate Foster Care Settings)

License Complaint Number: 202408354

CORRECTION ORDER

Dear Kayla Peltier:

On September 24, 2024, through September 27, 2024, a licensing review and licensing investigation of Beacon Specialized Living Minnesota Inc, located at 1355 Mendota Heights Road, Mendota Heights, 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 and licensing investigation, 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 1.

Violation: For two of nine persons whose records were reviewed (P1 and P5), the license holder did not provide orientation to internal and external reporting procedures for alleged or suspected maltreatment of vulnerable adults as required.

The license holder failed to provide P1, P1’s legal representative and P5’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of service initiation. P5’s legal representative was provided orientation to internal and external reporting procedures on December 29, 2023.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide orientation to P1 and P1’s legal representative on the VA maltreatment internal and external reporting procedures. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 2.

Violation: For five persons whose records were reviewed (P1, P3, P5, P6, and P9), the license holder did not meet the requirements for abuse prevention plans as required.

Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year.

a. The license holder failed to review P1’s individual abuse prevention plan (IAPP) annually in 2021 and 2023.

b. The license holder failed to develop the IAPP for P3 as part of the initial individual program plan or service plan in 2020. The IAPP was developed in 2021. Additionally, the license holder failed to review the IAPP annually in 2023.

c. P6’s services were initiated on July 21, 2023. The license holder failed to orientate P6 to the program’s program abuse prevention plan (PAPP) within 24 hours of admission.

d. The license holder failed to develop the IAPP for P5 as part of the initial individual program plan or service plan prior to or upon service initiation. P5’s service initiation date was December 23, 2023. The IAPP was developed on April 11, 2024, and reviewed with P5’s expanded support team on May 27, 2024.

Additionally, the license holder failed to include a statement of measures for P5 that will be taken to minimize the risk of abuse to the vulnerable adult when the individual assessment required in section 626.557, subdivision 14, paragraph (b), indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan.

e. The license holder failed to develop an IAPP for P9 as part of the initial individual program plan or service plan prior to or upon service initiation. P9’s service initiation date was November 3, 2022. The IAPP was developed on April 30, 2024.

Corrective Action Ordered: P6 no longer receives services from the license holder. Within 30 days of receiving this order, you must:

· review the IAPP with P5 and P9’s interdisciplinary team; and

· include a statement of measures that would be taken to minimize the risk of abuse to P5 and P9 in their IAPPs.

This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For six persons whose records were reviewed (P1, P2, P4, P6, P8, and P9), the license holder did not provide a written notice that identified the service recipient rights as required.

The license holder failed to provide P1, P2, P4, P6, P8, and P9 and their legal representatives with a written notice that identified the service recipient rights and an explanation of those rights annually.

Corrective Action Ordered: P4 and P6 no longer receive services from the license holder. Within 30 days of receiving this order, you must provide P1, P2, P2’s legal representative, P8, and P8’s legal representative, P9, and P9’s legal representative a written notice that identifies the service recipient rights and an explanation of those rights. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.04, subdivisions 2 and 3.

Violation: For two persons whose records were reviewed (P2 and P6), the license holder did not ensure the protection of the person’s rights in the services provided as required.

a. The license holder failed to review the need for a rights restriction for P2 at least semiannually from the date of initial approval.

b. DHS licensors visited the home in which P2 resided. DHS licensors observed that staff persons had moved personal items of P2’s into a locked room that P2 did not have access to. The license holder did not ensure that P2 had access to their personal possessions, and did not have a documented restriction of this right.

c. The license holder failed to maintain documentation that included the objective measures set as conditions for ending a rights restriction for P6.

d. The license holder was responsible for providing staff persons working with P6 additional training specific to P6’s needs. The license holder failed to provide the training. The license holder failed to ensure that P6 received services from an individual who is competent and trained, and who met qualifications identified in P6’s support plan and support plan addendum.

Corrective Action Ordered: P6 no longer receives services from the license holder. Immediately upon receiving this order, you must ensure P2 has access to all personal items not identified as part of a rights restriction.

Within 30 days of receiving this order, you must:

· review the need for P2’s rights restriction based on the conditions for ending the restriction;

· audit all records of persons with rights restrictions served by your program to ensure that the rights restrictions are reviewed according to established timelines; and

· submit the results of the audit to your licensor.

On an ongoing basis, you must ensure the schedules for reviewing restrictions are occurring semiannually, at a minimum, or more frequently if requested by the person, the person’s legal representative, if any, and case manager, as required in this subdivision. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For four people whose records were reviewed (P4, P6, P7, and P8), the license holder did not review and report medication and treatment issues as required.

a. The license holder was assigned responsibility for medication administration in P4’s, P6’s, and P7’s support plan addendums. The license holder failed to ensure information maintained in the medication administration record (MAR) was regularly reviewed at a minimum of every 3 months.

b. The license holder was assigned responsibility for medication administration in P8’s support plan. The license holder failed to report P8’s refusal to take or receive medication as prescribed on September 10, 2023, and October 2, 2023, to P8’s legal representative and case manager.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· audit MARs for all persons your program provides medication administration to from September 2024 to present to ensure that information maintained in the MARs is current and to identify medication administration errors;

· based on the results of the audit, you must report whether a dose of any medication was not administered, or treatment was not performed as prescribed to the person’s legal representative and case manager; and

· develop and implement a plan to correct patterns of medication administration errors when identified.

This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b).

Violation: For one person whose record was reviewed (P5), the license holder did not complete responsibilities related to psychotropic medication use and monitoring as required.

The license holder failed to maintain a description of the target symptoms that the psychotropic medication is to alleviate for P5. For the purposes of this section, "target symptom" refers to any perceptible diagnostic criteria for a person's diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation.

Corrective Action Ordered: Within 30 days of receiving this order, you must ensure P5’s support plan addendum contains a description of the target symptoms that the psychotropic medication is to alleviate for P5. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.06, subdivision 1.

Violation: For one person whose record was reviewed (P6), the license holder did not respond to incidents as required.

The license holder failed to maintain information about and report incidents to P6’s legal representative and case manager within 24 hours of an incident occurring on the following dates:

· On March 23, 2024, an incident occurred in which staff called 911. The case manager had not been notified of the incident at the time of the licensing review.

· On March 30, 2024, an incident occurred in which staff called 911. The legal representative and case manager had not been notified of the incident at the time of the licensing review.

· On May 2, 2024, an incident occurred in which staff called 911. An incident report had not been completed until May 6, 2024. The case manager was not notified of the incident until May 6, 2024.

· On May 11, 2024, an incident occurred in which P6 eloped from the program. The case manager was not notified of the incident until May 13, 2024.

· On May 11, 2024, a second incident occurred in which staff called 911. An incident report was not completed until May 13, 2024. The case manager was not notified of the incident until May 13, 2024.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For one person whose record was reviewed (P6), the license holder did not provide services in response to the person’s identified needs as required.

P6’s support plan addendum stated that P6 received a 2:1 staffing ratio, and that staff would supervise P6 at all times to ensure P6’s safety. The license holder failed to provide supervision as evidenced by the following:

· On August 11, 2023, P6 received a 1:1 staffing ratio and eloped from the home. P6 engaged in property destruction of the staff vehicle and stood in the middle of road. The license holder noted in an incident report dated August 11, 2023, that a neighbor witnessed the staff “trying to corral P6 with his car by pushing P6 with it.”

· On October 25, 2023, despite 2:1 staffing, P6 eloped from the home and ran into a nearby lake.

· On April 14, 2024, despite 2:1 staffing, P6 eloped from a community center and staff were unable to locate. P6 was found by law enforcement at a library.

· On September 14, 2024, despite 2:1 staffing, P6 eloped from the home twice and ran into a nearby lake.

· On September 19, 2024, despite 2:1 staffing, P6 eloped from the home and was found by law enforcement walking in a high traffic area. Staff were unaware that P6 had left the program.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.07, subdivision 2.

Violation: For four persons whose records were reviewed (P1, P4, P7, and P9), the license holder did not complete responsibilities related to service planning for basic support services as required.

a. The license holder failed to complete a preliminary support plan addendum based on the support plan for P7 and P9 within 15 calendar days of service initiation.

b. The license holder failed to review and revise the preliminary support plan addendum within 60 calendar days of service initiation for P1, P4, and P9 to document the 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.

Corrective Action Ordered: P4 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Statutes, section 245D.07, subdivision 3.

Violation: For two persons whose records were reviewed (P1 and P7), the license holder did not provide reports for basic services as required.

P1’s and P7’s support plan addendums document that the license holder will provide quarterly written reports regarding P1’s and P7’s progress or status to the person, their legal representative, and their case manager. The license holder failed to provide quarterly written reports for P1 and P7.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.071, subdivision 3.

Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services.

a. Regarding P5, the license holder failed to complete assessments, within the scope of services, in the following areas before the initial planning on December 23, 2023:

· the person’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments;

· the person’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and

· the person’s ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), 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.

These assessments were completed on April 11, 2024, for P5.

b. The license holder failed to meet, within 45 days of service initiation, with P5 and P6, their legal representatives, their case managers, and other members of the support teams to determine the following:

· the scope of the services to be provided to support the person’s daily needs and activities;

· desired outcomes and the supports necessary to accomplish the person’s desired outcomes;

· the person’s preferences for how services and supports are provided;

· whether the current service setting is the most integrated setting available and appropriate;

· opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences;

· opportunities for community access, participation, and inclusion in preferred community activities;

· opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community;

· opportunities to seek competitive employment and work at competitively paying jobs in the community;

· how services must be coordinated across other providers licensed under this chapter and members of the support team or expanded support team to ensure continuity of care and coordination of services; and

· a discussion of how technology might be used to meet the person’s desired outcomes.

The license holder completed the above assessments with P5 on April 11,2024.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Statutes, section 245D.071, subdivision 4.

Violation: For five persons whose records were reviewed (P3, P5, P6, P7, and P8), the license holder did not develop a service plan that documents the service outcomes and supports as required.

The license holder failed to document the following information in P3, P5, P6, P7, and P8’s current support plan:

· the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about:

o any changes or modifications to the physical and social environments necessary when the service supports are provided;

o any equipment and materials required; and

o techniques that are consistent with the person’s communication mode and learning style;

· the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected;

· the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and

· the names of the staff or position responsible for implementing the supports and methods.

Corrective Action Ordered: P6 no longer receives services from the license holder. Within 30 days of receiving this order, you must develop a service plan that documents the service outcomes and supports listed above for P3, P5, P7, and P8. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. Citation: Minnesota Statutes, section 245D.071, subdivision 5.

Violation: For two persons whose records were reviewed (P3 and P6), the license holder did not meet the requirements for service plan review and evaluation as required.

a. P3’s support plan addendum required annual service planning and support team meetings. The license holder failed to participate in annual service planning and support team meetings for P3 in 2021.

b. The license holder failed to summarize P6’s status and progress toward achieving the identified outcomes, make recommendations, and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods in a report available at the time of the service plan review meeting in 2024.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

14. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b).

Violation: For six persons whose records were reviewed (P1, P3, P5, P6, P7, and P9), the license holder did not provide written or electronic copies of policies and procedures as required.

The license holder failed to inform P1, P3, P5, P6, P7, and P9, their legal representatives, and case managers, of the following policies and procedures that affect a person’s rights within five working days of service initiation:

· grievance policy;

· service suspension;

· service termination; and

· emergency use of manual restraints.

Additionally, the license holder failed to provide the data privacy policy to P3, P5, P6, and P7, their legal representatives, and their case managers within five working days of service initiation.

Corrective Action Ordered: P6 no longer receives services from the license holder. Within 30 days of receiving this order, you must:

· inform and provide copies of the policies above mentioned to P1, P3, P5, P7 and P9’s legal representative and case manager;

· audit all person served records to ensure the above has been provided;

· maintain documentation of the audit results; and

· provide a copy of the data privacy policy to P3, P5, and P7’s legal representative and case manager.

This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

15. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For one person whose record was reviewed (P6), the license holder did not maintain documentation in the service recipient record as required.

The license holder failed to maintain documentation of a signed statement authorizing the license holder to act in a medical emergency when P6’s legal representative cannot be reached or is delayed in arriving.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.11, subdivision 2, clause (7).

Violation: For one person whose record was reviewed (P6), the license holder did not implement the incident reporting and review policy and procedures as required.

Between August 1, 2023, and September 19, 2024, P6 was involved in 34 incidents in which staff were unable to respond to P6’s supervision needs and required law enforcement intervention or a mental health crisis intervention team. The license holder failed to implement their incident reporting and review policy and procedures to protect the health and welfare of P6 and others. The license holder failed to conduct a review of incident reports for identification of incident patterns and implementation of corrective action as necessary to reduce occurrences and protect the health and safety of P6.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision.

17. Citation: Minnesota Rules, part 9544.0030, subpart 1.

Violation: For eight persons whose records were reviewed (P1, P2, P3, P5, P6, P7, P8, and P9), the license holder did not meet the requirements of positive support strategies as identified.

The license holder failed to evaluate with P1, P2, P3, P5, P6, P7, P8, and P9, whether the identified positive support strategies currently meet the standards in subpart 2 at least every six months as required.

Corrective Action Ordered: P6 no longer receives services from the license holder. Within 30 days of receiving this order, you must evaluate with P1, P2, P3, P5, P6, P7, P8, and P9 whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subpart.

18. Citation: Minnesota Rules, part 9544.0110.

Violation: For one person whose record was reviewed (P6), the license holder did not report incidents to the commissioner as required.

The license holder failed to use the behavior intervention report form required by the commissioner to report behavioral incidents involving P6 that resulted in a call to 911 to the commissioner.

Corrective Action Ordered: P6 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this part.

19. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For three of fourteen staff persons whose records were reviewed (SP9, SP12, and SP13), the license holder did not maintain a personnel record as required.

The license holder failed to document the following information in SP9’s, and SP12’s-13’s personnel records:

· the employee's date of hire; and

· documentation sufficient to determine the date of their first unsupervised direct contact with a person served by the program.

Corrective Action Ordered: On an ongoing basis, you must maintain personnel records for all staff as required in this subdivision.

20. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For six staff persons whose records were reviewed (SP9, SP10, SP11, SP12, SP13, and SP14), the license holder did not provide orientation training as required.

a. The license holder failed to provide SP9 training on the program abuse prevention plan within 60 days of hire.

b. SP10 was hired on January 15, 2024. The license holder failed to provide the following orientation training for SP10 within 60 days of hire:

· 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; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

SP10 was trained on data privacy requirements on March 27, 2024.

c. The license holder failed to provide the following orientation training for SP11 within 60 days of hire:

· the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures;

· the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

d. The license holder failed to provide SP12 with the following orientation training within 60 days of hire:

· the program abuse prevention plan according to the requirements in 245A.65, subdivision 3.

e. The license holder failed to provide SP13 with the following orientation training within 60 days of hire:

· the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; and

· basic first aid training within 60 days of hire.

f. The license holder failed to provide the following orientation training for SP14 within 60 days of hire:

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP9, SP10, SP11, SP12, SP13, and SP14 with the required training above. This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

21. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (a), (b) and (c).

Violation: For three staff persons whose records were reviewed (SP9, SP12 and SP13), the license holder did not provide orientation to individual service recipient needs as required.

The license holder failed to provide SP9, SP12, and SP13 with training on individual service recipient needs, including the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and the person’s IAPP within 60 days of hire.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· provide SP9, SP12 and SP13 orientation to individual service recipient needs as required above in this subdivision; and

· maintain documentation of the orientation provided to SP9, SP12, and SP13.

This compliance will be monitored onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

22. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For eleven staff persons whose records were reviewed (SP1, SP2, SP3, SP4, SP5, SP6, SP8, SP9, SP12, SP13, and SP14), the license holder did not provide annual training as required.

a. The license holder failed to provide SP1 with annual training in the following areas: