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May 16, 2025 Justin England-Sullivan, Authorized Agent Circle of Life Home Care Anishinaabe LLC 4100 Lexington Avenue North Suite 150 Saint Paul, Minnesota 55126 License Number: 1074358 (245D – HCBS) CORRECTION ORDER Dear Justin England-Sullivan: On April 24, 2025, a licensing review of Circle of Life Home Care Anishinaabe LLC, located at 4100 Lexington Avenue North, 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, paragraph (b). Violation: For four of seven persons whose records were reviewed (P3-P6), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder developed IAPPs for P3- P6 that indicated the person was susceptible to abuse; however, the license holder failed to include statements of the specific measures to be taken to minimize the risk of abuse to the person and other vulnerable adults. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the IAPP for P3-P6 to include statements of the specific measures to be taken to minimize the risk of abuse to the person and other vulnerable adults. Additionally, you must provide the person, their legal representative, and their case manager the opportunity to participate in the development of the IAPP. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P6), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was assigned the responsibility of meeting P6’s health service needs according to P6’s support plan addendum. The license holder failed to maintain documentation on how P6’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication assistance; and · use medical equipment safely and correctly according to written instructions from a licensed health professional for P6. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must document how P6’s health needs would be met, including a description of procedures detailed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For seven persons whose records were reviewed (P1-P7), the license holder did not maintain a service recipient record as required. The license holder failed to maintain progress or daily log notes recorded by the program in P1-P7’s record. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must begin recording and maintaining progress or daily log notes in the service recipient records for all person’s receiving services in your program. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P5), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P5 and their case manager of the following policies and procedures, and provide copies of those policies and procedures, within five working days of service initiation, including: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must inform and provide copies of the policies and procedures affecting a person’s rights to P5 and their case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P6), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate positive support strategies with P6 at least every six months. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P6 whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (b). Violation: For three of ten staff persons whose records were reviewed (SP1, SP3, and SP5), the license holder did not maintain documentation in the personnel record as required. The license holder failed to maintain documentation in SP1’s, SP3’s, and SP5’s personnel record sufficient to determine the date of first unsupervised and supervised direct contact with a person served by the program. Repeat Violation: In a correction order that DHS issued on January 28, 2025, you were previously found in violation of this same statute. 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Tammi Mitei, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6341
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