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May 23, 2025 Thomas Reiffenberger, Authorized Agent Lakes Homes and Program Development, Inc. 18226 324th Avenue Detroit Lakes, Minnesota 56501 License Number: 1070520 (245D- HCBS)
AMENDED CORRECTION ORDER Notice: This Amended Correction Order supersedes the amended Correction Order, dated May 14, 2025. The amended Correction Order dated May 14, 2025 removed facility license numbers that were not a part of the licensing review. This amended Correction Order corrects the licensing action referenced in the “notice” section. The original Correction Order, dated April 29, 2025 and the amended Correction Order May 14, 2025, must be destroyed. Dear Thomas Reiffenberger: On April 9 and 10, 2025, a licensing review of Lakes Homes and Program Development, Inc., located at 847 Highway 10 East, Detroit Lakes, 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: For one of eleven persons whose record was reviewed (P3), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours as required. The license holder failed to provide P3 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours of P3’s service initiation on March 22, 2024. The license holder provided the orientation to P3 on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For one person whose record was reviewed (P1), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required. The license holder failed to provide P1 with an orientation to the PAPP within 24 hours of admission when P1 moved to a new community residential site (CRS) location on July 17, 2019. Corrective Action Ordered: Immediately upon receiving this order, you must provide P1 with an orientation to the PAPP. Additionally, you must maintain documentation of this orientation in P1’s service recipient record. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P3), the license holder did not develop and review the individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP upon P3’s service initiation on March 22, 2024. The license holder developed an IAPP for P3 on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P3 and P4), the license holder did not provide service recipient rights as required. a. The license holder failed to provide P3’s legal representative a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation on March 22, 2024. The license holder provided P3’s legal representative the above-mentioned rights on May 31, 2024. b. The license holder failed to provide P1 a written notice that included the following rights: · receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person’s bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; and · a setting that is free from hazards that threaten the person’s health or safety. c. The license holder failed to provide P4 a written notice that included the following rights: · receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person’s bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin and insects; and · a setting that is free from hazards that threaten the person’s health or safety. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 and P2 with a written notice that includes the above mentioned rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.04, subdivision 3. Violation: For four persons whose records were reviewed (P2, P4, P7 and P8), the license holder did not ensure the exercise and protection of the person’s rights as required. a. The license holder failed to ensure the exercise and protection of P2’s and P4’s rights to have freedom and support to access food at any time. During the site visits to the facilities where P2 resided (CRS, license number 1070522) and where P4 resided (CRS, license number 1070533) on April 10, 2025, DHS licensors observed that the license holder maintained locks on the kitchen refrigerator and deep freezer. b. The license holder failed to ensure the exercise and protection of P8’s rights to have use of and free access to common areas in the residence and have freedom and support to access food at any time. The license holder developed a program abuse prevention plan for the CRS where P8 resided (CRS, license number 1097124) that indicated the lock on the kitchen door would only be used as needed for safety if staff were called away from the kitchen during meal preparation. During the site visit to the CRS on April 10, 2025, DHS licensors discovered that the license holder maintained a lock on the kitchen door and the kitchen could only be accessed with staff assistance. c. The license holder restricted P7’s protection-related right to choose visitors and time of visits and have privacy for visits with the person's spouse, next of kin, legal counsel, religious adviser, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person's bedroom. The license holder failed to maintain the following documentation in P7’s support plan or support plan addendum: · the objective measures set as conditions for ending the restriction; and · a schedule for reviewing the need for P7’s restriction based on the conditions for ending the restriction semiannually with P7’s legal representative and case manager. Corrective Action Ordered: Immediately upon receiving this order, you must ensure P2, P4 and P8 have access to food at any time. Within 30 days, you must determine if a restriction of P2’s, P4’s, and P8’s right to access food at any time is necessary to ensure the person’s health, safety, and well-being; and · if it is determined a rights restriction is necessary for P2, P4, or P8, you must document the following: o the justification for the restriction based on an assessment of the person’s vulnerability related to exercising the right without restriction; o the objective measures set as conditions for ending the restriction; o a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at minimum; and o signed approval for the restriction from the person’s legal representative; · revise P7’s rights restriction to include specific objective measures set as conditions for ending the restriction; · review P7’s need for a rights restriction, at least, semiannually with P7’s legal representative and case manager; and · ensure P8 has free access to common areas in the residence; On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not meet requirements for medication administration as required. a. The license holder failed to obtain written authorization from P3’s legal representative to administer medication or treatment. The license holder provided medication administration to P3 upon service initiation March 22, 2024. The license holder received written authorization from P3’s legal representative on May 31, 2024. b. The license holder failed to document in P1’s-P4’s medication administration records (MARs) the notation of when P1’s-P4’s medications or treatments were administered on multiple occasions during the months of January, February and March 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not review medication administration records (MAR) as required. a. The license holder failed to review P3’s MAR to identify medication administration errors at a minimum every three months. The license holder was assigned responsibility for medication administration for P3 on March 22, 2024. The license holder initiated reviews of P3’s MAR on January 1, 2025. b. The license holder failed to complete MAR reviews that identified medication administration errors for P1-P4: · The license holder completed a medication administration record review for P1 on February 28, 2025, for December 1, 2024-February 28, 2025, that identified no medication administration errors. DHS identified 43 medication administration errors for the same time span. · The license holder completed a medication administration record review for P2 on March 30, 2025, for February 1, 2025-March 30, 2025, that identified no medication administration errors. DHS identified 84 medication administration errors for the same time span. · The license holder completed a medication administration record review for P3 on March 31, 2025, for January 1, 2025-March 31, 2025, that identified no medication administration errors. DHS identified 79 medication administration errors for the same time span. · The license holder completed a medication administration record review for P4 on January 13, 2025, for November 1, 2024-December 31, 2024, that identified no medication administration errors. DHS identified 27 medication administration errors for the same time span. Corrective Action Ordered: Within 30 days upon receiving this order, you must: · develop and implement a plan to correct any patterns of medication administration or documentation errors; · maintain documentation of the plan in your program’s records; and · provide re-training to staff persons who are assigned the responsibility of medication administration record reviews to ensure the staff persons conduct medication administration reviews in compliance with the requirements of 245D.05, subdivision 4. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. The license holder failed to document a description of the target symptoms that P3’s psychotropic medications are to alleviate in P3’s support plan addendum. Corrective Action Ordered: Within 30 days upon receiving this order, you must maintain documentation in P3’s support plan that includes a description of the target symptoms that each psychotropic medication was to alleviate, as required in this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not meet the requirements for safeguarding and handling a person’s fund and property, as required. a. The license holder failed to implement the preferences of P2’s legal representative and case manager for receiving a statement that itemizes receipts and disbursement of funds on a quarterly basis. b. The license holder failed to obtain written authorization to assist P3 with safekeeping of funds and property within five working days of service initiation on March 22, 2024. The license holder did obtain written authorization from P3’s legal representative and case manager on May 31, 2024. Corrective Action Ordered: Within 30 days upon receiving this order, you must: · provide a statement to P2’s case manager and legal representative; and · maintain documentation in P2’s record when the program sends financial statements to P2’s case manager and legal representative. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For four persons whose records were reviewed (P8-P11), the license holder did not provide services in compliance with the requirements of this chapter and the federal waiver plans. The license holder provided community residential services to P8-P11. The license holder documented in the program abuse prevention plan for CRS license number 1097124 the use of two cameras within the residence to supervise P8. The license holder failed to provide services in compliance with the requirements of this chapter and the federal waiver plan when they did not complete consents for the use of monitoring technology for P8-P11 as required in the Community Based Service Manual (CBSM). Corrective Action Ordered: Within 30 days upon receiving this order, you must: · complete consents for the use of monitoring technology forms with P8-P11 or their legal representatives, as applicable, and maintain the consents their records; · consult with P8’s case manager and legal representative regarding the use of cameras for supervision; and · update P8’s support plan addendum to include details regarding the use of cameras to supervise P8. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P3), the license holder did not meet service planning requirements for basic support services as required. The license holder failed to complete a preliminary support plan addendum for P3 to document services that will be provided within 15 days of service initiation on March 22, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (d). Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning requirements for intensive support services. The license holder failed to discuss with P1 and P1’s support team how technology might be used to meet P1’s desired outcomes. The license holder documented in P1’s support plan addendum dated November 4, 2024, that they discussed technology. The information the license holder documented did not relate to how technology might be used to meet the person’s outcomes. Corrective Action Ordered: Within 30 days upon receiving this order, you must: · discuss with P1, P1’slegal representative, P1’scase manager, and other people as identified by the person or the person's legal representative how technology might be used to meet the person's desired outcomes; · document a summary of this discussion in P1’s support plan addendum. The summary must include: o a statement regarding any decision made related to the use of technology; and o a description of any further research that must be completed before a decision regarding the use of technology can be made. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not maintain service recipient records as required. a. The license holder failed to maintain progress or daily log notes for P2. b. The license holder failed to protect service recipient records against loss, tampering or unauthorized disclosure for P3’s respite service initiation. c. The license holder failed to maintain an admission form signed by P3’s legal representative, that included the following: · identifying information, including the person’s name, date of birth, address, and telephone number; · the name, address, and telephone number of the persons legal representative, a primary emergency contact, the case manage, and family members or others identified by the person or case manager; · service information, including service initiation information, verification of the person's eligibility for services, documentation verifying that services have been provided as identified in the support plan or support plan addendum according to paragraph (a), and date of admission or readmission; and · health information, including medical history, special dietary needs, and allergies. d. The license holder failed to maintain documentation to show a signed statement authorizing the license holder to act in a medical emergency when P3’s legal representative could not be reached. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for all service recipients. The license holder maintained the above-mentioned documents for P3 on May 31, 2024. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not inform and provide policies and procedures as required. a. The license holder failed to inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P3 and P3’s the case manager within five working days of service initiation. The license holder initiated P3’s services on March 22, 2024, and the license holder provided the policies and procedures to P3 and P3’s case manager on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P3), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to incorporate, in writing, positive support strategies to an existing treatment, service, or other individual plans for P3 upon service initiation March 22, 2024. The license holder incorporated positive support strategies in P3’s support plan addendum on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 16. Citation: Minnesota Rule 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P3), the license holder did not provide notice of the emergency use of manual restraint policy as required. The license holder failed to obtain written acknowledgment from P3’s legal representative of P3 being notified of the license holder’s policy on the emergency use of manual restraints upon service initiation. The license holder initiated P3’s services on March 22, 2024, and obtained written acknowledgement from P3’s legal representative on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 17. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of four staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide an orientation to 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 provide SP3 with an orientation to the license holder’s program abuse prevention plan (PAPP) within 72 hours of first providing direct contact services on March 17, 2020. b. The license holder failed to provide SP3 with an orientation on the program’s PAPP annually in 2021, 2022, and 2023. c. The license holder failed to provide SP4 with an orientation on the program’s PAPP annually in 2023 and 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct an audit of all staff persons in your program to ensure they are receiving orientation on the program’s PAPP within 72 hours of first providing direct contact services to persons served by the program and annually thereafter; · based on the results of this audit, develop and implement a plan to come into compliance with this subdivision; and · maintain documentation of this audit and plan at your program for review by DHS licensors. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide orientation training as required. a. The license holder failed to provide SP1 with orientation and training on the following topics within 60 calendar days of hire: · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe. b. The license holder failed to provide SP3 with orientation and training on the following topics within 60 calendar days of hire on March 13, 2020: · basic first aid. The license holder provided this training to SP3 in July 2020; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. The license holder provided this training to SP3 in March 2021. Corrective Action Ordered: Within 30 days upon receiving this order, you must provide SP1 with the above-mentioned training. 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 as soon as possible. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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