Minnesota

May 23, 2025

Carl Berget, Authorized Agent

Berget Foster Care

893 Christensen Avenue

Saint Paul, Minnesota, 55118

License Number: 1070336 (245D – HCBS)

CORRECTION ORDER

Dear Carl Berget:

On April 1, 2025, a licensing review of Berget Foster Care, located at 893 Christensen Avenue, 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 (a).

Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required.

The license holder initiated P1’s services on May 24, 2023. The license holder initiated P2’s services on August 30, 2023. The license holder failed to, within 24 or 72 hours of admission:

· provide P1 and P2 with an orientation to the program abuse prevention plan; and

· notify P2’s legal representative of this orientation.

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

· provide P1 and P2 with an orientation of the PAPP;

· notify P2’s legal representative of this orientation;

· maintain documentation of this orientation in P1’s and P2’s service recipient records;

· complete an audit of the records of all persons served by your program to ensure an orientation of the program abuse prevention plan has been provided; and

· maintain documentation of these audits in the person’s service recipient records.

Compliance with this order will be reviewed 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, paragraph (b).

Violation: For one person whose record was reviewed (P1), the license holder did not develop an individual abuse prevention plan (IAPP) prior to or upon service initiation, as required.

The license holder initiated P1’s services on May 24, 2023. The license holder developed an IAPP for P1 on June 5, 2023. The license holder failed to develop an individual abuse prevention plan prior to or upon service initiation.

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

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

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for service recipient rights 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 P1 and P2’s legal representative with a written notice that identified the following service recipient rights in the notice the license holder provided to P1’s legal representative on May 27, 2023, and to P2’s legal representative on August 21, 2023, and February 28, 2055:

· access to the person’s personal possessions at any time, including financial resources;

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· 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;

· a setting that is free from hazards that threaten the person’s health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

b. The license holder failed to provide a copy of the service recipient rights annually to P1 and P2’s legal representatives in 2024.

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

· complete an audit of the written notice that was most recently provided to persons or their legal representatives and ensure the notice included the rights detailed above;

· for persons or legal representatives that were not provided a written notice that included the rights detailed above, you must provide those persons and legal representatives with a written notice that includes these rights;

· obtain written acknowledgement of receipt of the written notice of the service recipient rights and an explanation of the rights from the person or their legal representative; and

· maintain this written acknowledgement in the person’s service recipient records.

Compliance with this order will be reviewed 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.05, subdivision 2, paragraph (c), clause 6.

Violation: For one person whose record was reviewed (P2), the license holder did not maintain medication administration records as required.

P2 was prescribed an as needed (PRN) medication for agitation. The license holder maintained documentation in P2’s medication administration record (MAR) that P2’s PRN medication was last administered on July 5, 2024. The prescription was for 30 tablets and DHS licensors counted 24 tablets remaining in the prescription bottle; therefore, the license holder administered the medication five additional times to P2. The license holder failed to ensure that a notation of when a medication or treatment is administered was documented on P2’s MAR.

Corrective Action Ordered: Within 30 days of receiving this order, you must review the MARs of all persons served by your program to ensure documentation is accurate. Compliance with this order will be reviewed 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.051, subdivision 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required.

The license holder was assigned the responsibility for medication administration for P1 and P2.

P1 and P2 were prescribed psychotropic medications. The license holder failed to maintain documentation that included a description of the target symptoms the psychotropic medication was to alleviate.

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

· develop and maintain documentation in P1’s and P2’s support plan addendums that includes a description of the target symptoms that each psychotropic medication was to alleviate;

· complete an audit of the support plan addendums of all persons served by your program that you are assigned the responsibility for medication administration to determine if a description of target symptoms that each psychotropic medication was to alleviate was documented; and

· maintain documentation of these audits in each person’s service recipient record.

Compliance with this order will be reviewed 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.06, subdivision 4.

Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for safekeeping of funds and property as required.

The license holder initiated P2’s services on August 30, 2023, and assisted P2 with the safekeeping of funds. The license holder failed to:

· obtain authorization from P2’s legal representative and case manager to assist P2 with the safekeeping of funds and property within five working days of service initiation,

· renew the authorization annually, and

· survey, document and implement the preferences for frequency of receiving a statement that itemizes receipts and disbursements of funds.

The license holder obtained authorization to assist P2 with the safekeeping of funds from P2’s legal representative and case manager on February 20, 2025.

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

· survey and document P2’s case manager’s preferences for frequency of receiving an itemized statement of receipts and disbursement of funds;

· maintain documentation of this preference in P2’s service recipient record;

· complete an audit of the funds and property authorizations of all persons served by your program to determine the person’s or the person’s legal representative’s and case manager’s preference of frequencies of receiving an itemized statement of disbursement of funds and property; and

· maintain documentation of this audit in each person’s service recipient record.

Compliance with this order will be reviewed 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.071, subdivision 3, paragraph (b).

Violation: For two persons whose records are reviewed (P1 and P2), the license holder did not complete assessments as required.

The license holder failed to complete assessments for P1 and P2 that produced information about the person that describes the person’s overall strengths, functional skills and abilities.

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

· complete assessments for P1 and P2 that produce information about the person that describes the person’s overall strengths, functional skills and abilities in the assessed areas; and

· complete an audit of the assessments of all persons served by your program to determine if assessments include the person’s overall strengths, functional skills and abilities in the assessed areas; and

· review and revise the assessments.

Compliance with this order will be reviewed on site at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statues, 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.

a. The license holder initiated P1’s services on May 24, 2023. The license holder failed to inform P1 and P1’s case manager of and provide copies of the following policies and procedures within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy.

The license holder informed P1 and P1’s case manager of the license holder’s grievance policy and procedure and provided a copy of the policy and procedure on June 5, 2023.

b. The license holder initiated P2’s services on August 30, 2023. The license holder failed to inform P2’s case manager of and provide copies of the following policies and procedures within five working days of service initiation:

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy.

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

· inform P1, P2 and P1’s and P2’s case managers of, and provide copies of, the above-mentioned policies and procedures;

· obtain a written acknowledgement from P1, P1’s case manager, P2’s legal representative and P2’s case manager documenting that they have received copies of the above-mentioned policies and procedures;

· maintain copies of the written acknowledgements in P1’s and P2’s service recipient records;

· complete an audit of the records of all persons served by your program to determine compliance with the above-mentioned subdivision; and

· maintain documentation of this audit in the person’s service recipient records.

Compliance with this order will be reviewed onsite 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.071, subdivision 3, paragraph (d).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete initial service planning for intensive support services as required.

The license holder failed to have a discussion of how technology might be used to meet the person’s desired outcomes at P1’s and P2’s 45-day initial service planning meetings.

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

· discuss with the person, their case manager, their legal representative (as applicable), and members of the support team about how technology might be used to meet the person’s desired outcomes;

· you must include a summary of this discussion in the person’s support plan or support plan addendum. This discussion must include:

o a statement in the summary regarding any decision that is made regarding the use of technology;

o and a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

Compliance with this order will be reviewed onsite 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.071, subdivision 4, paragraph (b).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required.

The license holder failed to document the supports and methods to accomplish outcomes, including the methods or actions that will be used to support the person.

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

· document 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.

Compliance with this order will be reviewed onsite 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.071, subdivision 5, paragraph (g).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for service plan review and evaluation.

a. The license holder documented in P1’s and P2’s support plan addendums that semiannual service plan meetings were required for P1 and P2. The license holder failed to participate in semiannual service plan review meetings for P1 and P2 semi-annually.

b. The license holder documented in P1’s and P2’s support plan addendums that semiannual written reports summarizing the person’s status and progress towards achieving identified outcomes were required for P1 and P2. The license holder failed to provide written reports semi-annually.

c. The license holder failed to discuss with P1 and P2, P2’s legal representative and members of P1’s and P2’s support teams about how technology might be used to meet P1’s and P2’s desired outcomes at least once per year.

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

· complete written reports for P1 and P2 that provide the above-mentioned information;

· provide copies of the written reports to P1’s and P2’s legal representatives and case managers;

· complete an audit of the written report frequencies assigned in the support plan addendums of all persons served by your program;

· complete written reports for any person whose established written report frequency is more frequent than once per calendar year and provide the written reports to the person’s support team; and

· maintain documentation of these audits in each persons’ service recipient record.

Compliance with this order will be reviewed onsite 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.095, subdivision 3.

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

The license holder failed to maintain progress or daily log notes for P1 and P2.

Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes for all persons served by your program. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. Citation: Minnesota Rules, 9544.0030, subpart 1.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate positive support strategies at least every six months as required.

The license holder failed to evaluate the identified positive support strategies with P1 and P2 at least every six months.

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

· evaluate the identified positive support strategies with P1 and P2;

· based upon the results of the evaluation, determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes;

· maintain documentation of this evaluation in P1’s and P2’s service recipient records;

· complete an audit of the service recipient records of all persons served by your program to determine whether identified positive support strategies have been evaluated at least every six month;

· for any person who you have not evaluated the positive support strategies in the past six months you must complete the evaluation with the person and document the evaluation in the person’s service recipient record; and

· maintain documentation of these evaluations in the person’s service recipient records.

Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual training as required.

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

a. The license holder failed to provide annual training to SP1 on the following topics:

· data privacy requirements according to Minnesota Statutes, 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 license holder did not provide this training to SP1 in 2020, 2021, and 2022;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04. The license holder did not provide this training to SP1 in 2020, 2021, 2022, 2023, and 2024;

· 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. The license holder did not provide this training to SP1 in 2020, 2021, 2022, 2023, and 2024;

· the license holder’s program abuse prevention plan (PAPP). The license holder did not provide this training to SP1 in 2023;

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person. The license holder did not provide this training in 2020, 2021, 2022, and 2024;

· 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. The license holder did not provide this training to SP1 in 2020, 2021, and 2022;

· 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. The license holder did not provide this training to SP1 in 2020, 2021, and 2022; 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 did not provide this training to SP1 in 2020, 2021, 2022, 2023, and 2024.

b. The license holder failed to provide annual training to SP2 on the following topics:

· the license holder’s program abuse prevention plan (PAPP). The license holder did not provide this training to SP2 in 2023;

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they appliced to direct support service provided by the staff person. The license holder did not provide this training to SP2 in 2023; and

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

· provide SP1 and SP2 with training the above-mentioned annual training topics; and

· maintain documentation of this training in SP1’s and SP2’s personnel records.

Compliance with this order will be reviewed 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.081.

Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight.

a. The license holder failed to ensure that the staff person (SP1) the license holder identified as the designated coordinator provided supervision, support, and evaluation of activities that included:

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

· taking the action necessary 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 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 program coordination and oversight of the services is evidenced in citations 1 through 15.

b. The license holder failed to ensure that staff person (SP1) the license holder identified as the designated manager performed the required program management and oversight of the services provided by the license holder that included:

· maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g);

· ensuring the duties of designated coordinator are fulfilled according to the requirements in subdivision 2;

· ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct care staff’s ability to perform the job functions based on direct observation are completed by the license holder; and

· evaluating the information identified in clauses (1) through (6) to develop, document, and implement ongoing program improvements.

The failure to provide program management and oversight of the services provided is evidenced in citations 1 through 15.

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

· develop a comprehensive plan for how you will come into compliance with the requirements of 245D, 245A, and the Positive Support Rule, and maintain compliance with the requirements;

· ensure all staff persons identified as designated coordinators and/or designated managers for the program understand and have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3;

· submit the following to your licensor:

o the plan you have developed to come into and maintain compliance; and

o documentation that the designated coordinators and designated managers have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision.

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

1. By secure email at kate. spenger@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: Kate Spenger

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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.

Kate Spenger, Human Services Licensor

Licensing Division

Office of Inspector General

651-431-5757

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