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May 5, 2025 Shavon Rush, Authorized Agent Caring Helpful Hands 121 Washington Avenue North Suite 205 Minneapolis, Minnesota 55401 License Number: 1110822 (245D – HCBS) CORRECTION ORDER Dear Shavon Rush, On April 24, 2025, a licensing review of Caring Helpful Hands, located at 121 Washington Avenue North, Suite 205, Minneapolis, 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 1. Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. The license holder failed to include a secondary person or position to whom internal reports may be made when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment. The secondary person identified is no longer affiliated with the program. Corrective Action Ordered: Within 60 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. You must also submit your revised written policy to your licensor. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 2. Citation: Minnesota Statutes, section 245D.095, subdivision 2. Violation: The license holder did not maintain an admission and discharge register as required. The license holder failed to keep a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred. Corrective Action Ordered: Within 60 days of receiving this order, you must: • complete a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service termination initiated by the license or deaths; and • submit evidence of this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not establish and enforce an individual abuse prevention plan (IAPP) as required. 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 develop an IAPP for P1 that included: · an individualized assessment of P1’s susceptibility to self-abuse. P1’s IAPP indicated they were not susceptible to self-abuse; however, that was not consistent with information maintained in P1’s record. P1’s support plan addendum indicated P1 needed assistance with money management, medication assistance, and mental health support. b. The license holder failed to develop an IAPP for P2 that included: · an individualized assessment of P2’s susceptibility to self-abuse. P2’s IAPP was not consistent with information maintained in P2’s record. P2’s support plan addendum indicated P2 needed assistance with home management and health related supports. c. The license holder failed to review and evaluate P1’s IAPP in 2023 and 2024, as well as review and evaluate P2’s IAPP in 2024 and 2025. Corrective Action Ordered: Within 60 days of receiving this order, you must: · revise P1’s and P2’s IAPPs to include the above-mentioned areas; · review P1’s and P2’s IAPPs with their interdisciplinary teams; · maintain this documentation in P1’s and P2’s records; and · submit evidence of this to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide service recipient rights as required. The license holder failed to provide P1 with service recipient rights annually in 2024. P1 was provided with service recipient rights on August 1, 2023, and December 1, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2 and 3. Violation: For one person whose record was reviewed (P1), the license holder did not complete responsibilities related to service planning for basic support services as required. a. The license holder failed to establish a timeline for service planning and support team meetings in P1’s support plan addendum with P1 and P1’s expanded support team. b. The license holder failed to provide written reports regarding P1’s progress as assigned in P1’s support plan addendum. P1’s support plan addendum indicated that reports were requested annually. Corrective Action Ordered: Within 60 days of receiving this correction order, you must meet with P1’s expanded support team for a service planning and support team meeting and discuss the above mentioned. You must also provide P1 and P1’s support team with an annual progress report. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to provide P1’s and P2’s case managers copies of the program’s policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension policy and procedure; · service termination policy and procedure; and · emergency use of manual restraint policy and procedure. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the above-mentioned policies and procedures to P1’s and P2’s case managers. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not evaluate positive support strategies as required. The license holder failed to, at least every six months, review and evaluate with P2 the identified positive support strategies and, based upon the results of the evaluation, determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes. The license holder kept record of the positive supports record being completed in 2024 with P2, but date of completion was not documented. This was most recently reviewed with P2 on March 1, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2) the license holder did not provide orientation and annual training to the orientation of mandated reporters as required. a. The license holder failed to provide SP1 and SP2 with annual training in 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 as required. b. The license holder failed to provide SP2 with an orientation training within 72 hours of first providing direct contact services to persons served in 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 as required. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP1 and SP2 with an orientation to the training requirements identified above; · complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter; · provide any lapsed trainings identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and · submit a record of completed training to your assigned licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. The license holder failed to provide SP1 and SP2 with an orientation to the following within 60 calendar 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 (HIPPA), 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; · 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. b. The license holder failed to provide SP2 with an orientation to the following within 60 days of hire: · the license holder’s current policies and procures required under Minnesota Statutes, chapter 245D, including their location, access, and staff responsibilities related to the implementation of those policies and procedures, including: o consumer grievance and complaint procedures; o consumer temporary service suspension; o consumer service termination; o prohibition of drug and alcohol use policy; and o emergency use of manual restraint. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP1 and SP2 with an orientation to the training requirements identified above; · complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter; · provide any lapsed trainings identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and · submit a record of completed training to your assigned licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. 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. The license holder failed to provide SP1 and SP2 with the following training before having unsupervised direct contact with a person served by the program: · orientation to the individual service recipient needs; · the person’s support plan or support plan addendum; and · the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP1 and SP2 with an orientation to the training requirements identified above; · complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter; · provide any lapsed trainings identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and · submit a record of completed training to your assigned licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual training as required. The license holder failed to provide SP1 and SP2 with annual training on the following topics prior to or within the same month of the subsequent calendar year as required: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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; · 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 and SP2 with the annual training requirements identified above; · complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter; · provide any lapsed trainings identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and · submit a record of completed training to your assigned licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. a. The license holder failed to maintain personnel records for SP1 and SP2 that documented staff orientation and training, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. b. Additionally, the license holder failed to maintain documentation in SP1 and SP2’s personnel record or elsewhere, sufficient to determine the date of first supervised direct contact with a person served by the program, and the date of first unsupervised contact with a person served by the program.
Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.10, subdivision 3a. Violation: The license holder did not establish and maintain policies and procedures related to service termination as required. The license holder failed identify “the safety of the person, others in the program, or staff is endangered and positive support strategies were attempted and have not achieved and effectively maintained safety for the person or others” as a condition for terminating services in the license holder’s policy and procedure for service termination. Corrective Action Ordered: Within 60 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. You must also submit your revised written policies to your licensor. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 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 kelly.bosch@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: Kelly Bosch 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 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 as soon as possible. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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