May 5, 2025

Joseph Salas

Homestay Services, LLC

765 Minnehaha Ave W

St. Paul, MN 55104

License Number: 1094658 (245D – Home and Community-Based Services)

CORRECTION ORDER

Dear Joseph Salas:

On March 13, 2025, a licensing review of Homestay Services LLC, located at 765 Minnehaha Ave W St. Paul, MN, 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, paragraph (b).

Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not develop and review the individual abuse prevention plans (IAPP) as required.

a. The license holder failed include the following in P1’s IAPP:

· a statement of measures that would to be taken to minimize the risk of abuse to P1 when the individual assessment required in Minnesota Statutes, section 626.557, subdivision 14, paragraph (b), indicated the need for measures in addition to the specific measures identified in the IAPP;

· the specific actions the program would take to minimize the risk of abuse within the scope of the licensed services and identified referrals made when P1 was susceptible to abuse outside the scope or control of the licensed services; and

· documentation of the determination when the assessment indicated that P1 did not need specific risk reduction measures.

b. The license holder failed to develop an IAPP that accurately assessed P2’s susceptibility to abuse by other individuals. The license holder developed an IAPP for P2 that assessed that P2 was not susceptible to abuse. This was inconsistent with communication from SP2, and information elsewhere in P2’s record. P2’s support plan indicates that P2 has limited mobility and limited use of his left side and would be susceptible to physical abuse. Additionally, the license holder failed to review P2’s IAPP annually in 2024.

Corrective Action Ordered: Within 60 days of receiving of this order, you must:

· develop an IAPP for P1 that includes the information detailed above. Additionally, you must ensure P1 participates in the development of the IAPP to the full extent of the P1's abilities and give P1's legal representative the opportunity to participate in the development of the plan. You must document the review of P1’s IAPP at least annually with P1’s interdisciplinary team, using the individual assessment and any reports of abuse relating to P1. The plan shall be revised to reflect the results of this review; and

· update P2’s IAPP to reflect the risks associated with physical abuse as indicated in P2’s assessed individual needs.

Compliance with corrective action will be monitored at an upcoming licensing monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide service recipient rights as required.

a. The license holder provided P1 multiple services and failed to provide P1 or P1’s legal representative with written notice that identified the service recipient rights and an explanation of those rights within five days of each service initiation and annually thereafter.

b. The license holder failed to provide P2 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2024. 

Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1 or P1’s legal representative and P2 with a written notice of service recipient rights as required in Minnesota Statutes, section 245D.04 subdivision 2 and 3. Compliance with corrective action will be monitored at an upcoming licensing monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not document health needs as required.

a. The license holder provided medication assistance to P1. The license holder failed to maintain documentation of how P1’s health needs would be met, including a description of the procedures the license holder would follow in order to provide medication assistance.

b. The license holder provided P2 with medication assistance and assistance with appointments. The license holder failed to maintain documentation of how P2’s health needs would be met, including a description of the procedures the license holder would follow in order to:

· provide medication assistance; and

· assist with or coordinate medical, dental and other health service appointments.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· review and revise P1 and P2’s support plan addendum to document how the license holder will meet P1 and P2’s health needs;

· audit, and revise as determined, all person served records to ensure the above is documented; and

· maintain documentation of the audit results.

Compliance with corrective action will be monitored at an upcoming licensing monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not complete assessment and initial service planning as required.

a. The license holder failed to complete P1’s preliminary support plan addendum within 15 days of service initiation.

b. The license holder failed to complete assessments for P1 in the following areas before providing 45 days of service:

· P1’s ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments;

· P1’s ability to self-manage personal safety to avoid injury or accident in the service setting, including, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and

· P1’s ability to self-manage symptoms or behaviors that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) and (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of P1 or others.

c. The license holder failed to hold an initial planning meeting with P1, P1’s legal representative, P1’s case manager, and other members of P1’s support team, before providing 45 days of service to determine the following:

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

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

· the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule;

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

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

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

· 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 serving the person and members of the support team to ensure continuity of care and coordination of services for the person; and

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

Corrective Action Ordered: Within 60 days of receipt of this order, you must:

· complete and document the results of the assessment as detailed above in paragraph (b); and

· hold a planning meeting with P1, P1’s legal representative, and P1’s case manager to determine the information detailed above in paragraph (c).

Compliance with corrective action will be monitored at an upcoming license monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P1), the license holder did not develop a service plan as required.

The license holder failed to develop P1’s service plan that documented service outcomes and supports within ten days of the initial service planning meeting, including:

· 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: Within 30 days of receipt of this order, you must develop a service plan for P1 that documents service outcomes and supports as detailed above. Compliance with corrective action will be monitored at an upcoming license monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for positive support strategies as required.

The license holder failed to incorporate in writing to an existing treatment, service, or other individual plan, the positive support strategies to be used while providing services to P2.

Corrective Action Ordered: Within 60 days of receiving this order, you must:

· Assess the person’s strengths, needs, and preferences to identify and create positive support strategies;

· incorporate in writing to an existing treatment, service or other individual plan, the positive support strategies to be used while providing services to P2;

· audit, and revise as determined, all person served records to ensure this has been completed; and

· maintain documentation of the audit results.

This compliance will be monitored on-site 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.09, subdivision 4a, paragraph (a).

Violation: For one of two staff persons whose record were reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required.

The license holder failed to provide orientation to the individual service recipient needs to SP1 prior to SP1’s having unsupervised contact with persons served by the program.

Corrective Action Ordered: Within 60 days of receiving this order, you must

· provide SP1 with the above training;

· audit all staff personnel records to ensure the above has been provided;

· provide training as determined by the audit; and

· maintain documentation of the audit results.

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

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

Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to program requirements.

The license holder failed to provide SP1 with orientation to the program 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;

· 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;

· 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;

· 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;

· 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; and

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

Corrective Action Ordered: This compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. 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.

The license holder failed to provide SP1 with annual training 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;

· 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;

· 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;

· 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;

· 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; and

· 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 60 days of receiving this order, you must:

· provide SP1 with the above training;

· audit all staff personnel records to ensure the above has been provided;

· conduct training as determined by the audit; and

· maintain documentation of the audit results.

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

10. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (b).

Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain a personnel record as required.

The license holder failed to maintain documentation in SP1’s personnel record or elsewhere, sufficient to determine the date of SP1’s first supervised direct contact with a person served by the program and the date of first unsupervised direct contact with a person served by the program.

Corrective Action Ordered: This compliance will be monitored on-site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Statutes, section 245D.081, subdivision 2.

Violation: The license holder did not ensure the delivery and evaluation of services provided were coordinated by the designated staff person as required.

The designated coordinated identified by the license holder (SP3) failed to provide supervision, support, and evaluation of activities that include:

· oversight of the license holder’s responsibilities assigned in the person’s service and support plan and the service and support plan addendum;

· taking the necessary action to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07;

· instruction and assistance to direct support staff implementing the support plan and the service outcomes; including direct observation of service delivery sufficient to assess staff competency; and

· evaluation of the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07

The failure to provide coordination and evaluation of individual service delivery is evidenced in citations 1 through 10.

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

· designate a person other than SP3 be appointed as the designated coordinator, who is responsible for delivery and evaluation of services provided by the license holder.

· submit the name, contact information and qualifications of the person(s) you have designated and have ensured is competent to perform the duties of the designated coordinator as required in this section; and

· submit a signed acknowledgement that the newly designated person has reviewed and understands the responsibilities of a designated coordinator according to 245D.081, subdivision 2, paragraph (a).

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

12. Citation: Minnesota Statutes, section 245D.081, subdivision 3.

Violation: The license holder did not ensure that the designated managerial staff person provided program management and oversight of the services provided as required.

The designated manager identified by the license holder (SP4) failed to provide program management and oversight of the services provided by being responsible for the following:

· maintaining a current understanding of the license requirements sufficient to ensure compliance throughout the program;

· ensuring the duties of the designated coordinator are fulfilled; and

· ensuring staff competency requirements are met.

The failure to provide program management and oversight of services provided is evidenced in citations 1 through 10.

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

· designate a person, other than SP4 to be appointed as the designated manager, who is responsible for delivery and evaluation of services provided by the license holder.

· submit the name, contact information and qualifications of the persons(s) you have designated and ensured is competent to perform the duties of the designated manager as required in this section; and

· submit a signed acknowledgement that the newly designated person has reviewed and understands the responsibilities of designated manager according to 245D.081, subdivision 3, paragraph (a).

This compliance will be monitored on-site at an upcoming compliance monitoring visit. 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.

Submissions required as part of a corrective action ordered must be sent to your Licensor at:

1. By secure email at coty.aust@state.mn.us; or

2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below:

Commissioner, Department of Human Services

ATTN: Coty Aust

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 64953

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.

Coty Aust, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-4605

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/