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May 23, 2025 Rachel Dressen, Authorized Agent Rachel Jeanne Dressen 71912 240th Street Albert Lea, Minnesota, 56007 License Number: 1116460 (245D – HCBS) CORRECTION ORDER Dear Rachel Dressen: On April 2, 2025, a licensing review of Rachel Jeanne Dressen, located at 71912 240th Street, Albert Lea, 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 and 2. Violation: For one of one person whose record was reviewed (P1), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. a. The license holder failed to provide P1 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. b. The license holder initiated P1’s services on June 10, 2023. The license holder failed to provide P1 with an orientation to the license holder’s PAPP within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide an orientation to the internal and external reporting procedures and the PAPP to P1; · notify P1’s legal representative of the orientation; and · maintain documentation of this orientation in P1’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. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. The license holder initiated P1’s services on June 10, 2023. The license holder failed to develop an IAPP as part of the initial individual program plan or service plan prior to or upon service initiation. The license holder developed P1’s IAPP on June 27, 2023. b. The license holder failed to review P1’s IAPP annually in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P1’s IAPP with P1, P1’s case manager and members of the support team; and · document this review of the IAPP in P1’s support plan addendum. 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. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide a written notice that identified the 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 P1’s legal representative with a written notice that identified the service recipient’s rights in subdivision 2 and 3 and an explanation of those rights within five working days of service initiation. b. The license holder failed to provide P1 and P1’s legal representative with a written notice that identified the service recipient’s rights and an explanation of those rights annually in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 and P1’s legal representative with a copy of the service recipient rights and an explanation of those rights; and · maintain documentation of the receipt of the rights and an explanation of the rights in P1’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. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not maintain documentation of how health needs would be met, as required. The license holder was assigned responsibility of meeting P1’s health needs. The license holder failed to 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: · assist with or coordinate medical, dental, and other health service appointments; or · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Correction Action Ordered: Within 30 days of receiving this order, you must document the above-mentioned information in P1’s support plan addendum. 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.05, subdivision 2, paragraph (c). Violation: For one person whose record was reviewed (P1), the license holder did not maintain medication administration records as required. The license holder failed to ensure the following information was documented in P1’s medication administration record: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information must be readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and o the occurrence of possible adverse reactions to the medication or treatment; · notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made; and · notation of when a medication or treatment was started, administered, changed, or discontinued. Corrective Action Ordered: Immediately upon receiving this order, you must: · maintain the above-mentioned documentation in P1’s medication administration record; and · provide training on the above-mentioned information to all staff who are responsible for administering medication to P1. You must maintain documentation of this training in the staff person’s personnel 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.05, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not complete medication administration record reviews as required. The license holder was assigned the responsibility for medication administration to P1. The license holder failed to conduct a medication administration record review of P1’s medication administration records, at a minimum, every three months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete medication administration record reviews for January 2025 to current for P1 to ensure the following: o the information maintained in the medication administration record is current; and o to identify medication administration errors. Based on the review, the license holder must develop and implement a plan to correct patterns of medication administration errors when identified; and · maintain documentation of the medication administration reviews in P1’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.06, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for the safekeeping of funds and property as required. The license holder failed to obtain written authorization to assist P1 with the safekeeping of funds and property within five working days of service initiation. At the time of the licensing review, the license holder had not obtained authorization from P1’s legal representative. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P1’s legal representative to assist P1 with the safekeeping of funds and property; · maintain this authorization in P1’s service recipient record; and · obtain this written authorization annually. 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. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet initial service planning requirements for intensive support services as required. a. The license holder failed to meet with P1, P1’s legal representative, case manager, and other members of the support team before providing 45 days of service to determine: · the scope of the 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; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded 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. b. The license holder failed to complete assessments for P1 in the following areas: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person’s ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. Additionally, assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms. c. The license holder failed to develop a service plan that documented service outcomes and supports for P1. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete the required assessments for P1 that produce information about the person that describes the person’s overall strengths, functional skills, and abilities; · meet with P1, P1’s case manager, P1’s legal representative and members of the support team to determine the above-mentioned items and to have a discussion about how technology might be used to meet P1’s desired outcomes. You must include a summary of the discussion about technology in P1’s support plan addendum. This summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. · review the results of the assessments of P1’s ability to self-manage health and medical needs, personal safety, and symptoms or behaviors with P1, P1’s case manager, P1’s legal representative and members of the support team. You must document this review in P1’s service recipient record; · develop a service plan for P1 that documents the service outcomes and supports that include the following: o the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: · any changes or modifications to the physical and social environments necessary when the service supports are provided; · any equipment and materials required; and · techniques that are consistent with the person’s communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o 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 o the names of the staff or position responsible for implementing the supports and methods. 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 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for service plan review and evaluation as required. a. The license holder failed to participate in a service plan review meeting for P1 at least once per year in 2024 that included the following: · a discussion with P1, P1’s case manager, P1’s legal representative and members of P1’s support team of how technology might be used to meet P1’s desired outcomes; and · a discussion with P1 and P1’s case manager of options to transition P1 out of a community setting controlled by the provider and into a setting not controlled by a provider. b. The license holder failed to complete written reports that summarized P1’s status and progress toward achieving desired outcomes at least once per year. Corrective Action Ordered: Within 60 days of receiving this order, you must: · discuss the following with P1, P1’s legal representative, P1’s case manager and members of the support team: o the frequency for service plan review meetings and written reports; o how technology might be used to meet P1’s outcomes as ordered in citation number 8; o discuss with P1, P1’s case manager, P1’s legal representative and members of P1’s support team, options to transition P1 out of a community setting controlled by the provider and into a setting not controlled by the provider. You must document a summary of this discussion in the support plan addendum for P1. The summary must include: · a statement about any decision made regarding transitioning out of a provider-controlled setting; and · a description of any further research or education that must be completed before a decision regarding transitioning out of a provider-controlled setting 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 Statues, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not provide did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P1 and P1’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the above-mentioned policies and procedures to P1, and P1’s case manager; · obtain written acknowledgement from P1’s legal representative that P1 and P1’s legal representative has been notified of the program’s emergency use of manual restraints policy and procedure as required in Minnesota Rule 9544.0080; and · maintain documentation that P1 and P1’s case manager were informed of these policies in P1’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. 11. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate with P1 the identified positive support strategies at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate with P1, the identified positive support strategies; · maintain documentation of this evaluation in P1’s service recipient record; and · evaluate the positive support strategies with P1 at least every six months. 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 one person whose record was reviewed (P1), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes for P1. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes in P1’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. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of seven staff persons whose records were reviewed (SP1), the license holder did not review the program abuse prevention plan (PAPP) as required. The license holder failed to provide an annual review of the PAPP to SP1 in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 with a review of the PAPP and maintain documentation of this review in SP1’s personnel 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. 14. Citation: Minnesota Statutes, section 245D.09, subdivisions 4 and 4a. Violation: For seven staff persons whose record was reviewed (SP1 through SP7), the license holder did not provide orientation as required. The license holder failed to provide orientation training to SP1 through SP7 on the following topics within 60 calendar days of hire: · job description and how to complete specific job functions, including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · 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; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · other topics as determined necessary in the person’s support plan by the case manager or other areas identified by the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the above-mentioned orientation to SP1 through SP7; · maintain documentation of this orientation in SP1’s through SP7’s personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (a). Violation: For seven staff persons whose records were reviewed (SP1 through SP7), the license holder did not provide an orientation to individual service recipient needs as required. The license holder failed to provide SP1 through SP7 with the following orientation training before having unsupervised direct contact with a person served by the program: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 through SP7 with the above-mentioned trainings; and · maintain documentation of this training in SP1’s through SP7’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. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (d). Violation: For seven staff whose records were reviewed (SP1 through SP7), the license holder did not provide medication administration orientation and training as required. The license holder failed to provide SP1 through SP7 with medication administration training prior to administering medication to a person served by the program. Corrective Action Ordered: Immediately upon receiving this order, you must: · implement a medication administration training curriculum developed by a registered nurse or appropriate licensed health professional. The training must incorporate an observed skill assessment conducted by the trainer; and · provide all staff who administer medication with medication administration training from the curriculum developed by a registered nurse or appropriate health professional. You must document the training in the staff person’s personnel 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. 17. Citation: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (e). Violation: For seven staff persons whose records were reviewed (SP1 through SP7), the license holder did not provide orientation to life sustaining medical equipment as required. P1 required g-tube feedings and utilized a percussion vest. The license holder failed to provide SP1 with instruction on the safe and correct operation of medical equipment used by P1 to sustain life or to monitor a medical condition that could become life-threatening without proper use of the medical equipment. Corrective Action Ordered: Immediately upon receiving this order, you must: · provide SP1 through SP7 with an orientation to P1’s life sustaining medical equipment; and · maintain documentation of this orientation in SP1’s through SP7’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. 18. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For seven staff persons whose records were reviewed (SP1 through SP7), the license holder did not provide annual training as required. The license holder failed to provide SP1 through SP7 with annual training on the following topics in 2024: · 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; · basic first aid; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · other topics determined necessary in the person’s support plan by the case manager or other areas identified by the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 through SP7 the training ordered in citation number 14. 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. 19. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For seven staff persons whose records were reviewed (SP1 through SP7), the license holder did not maintain personnel records as required. The license holder failed to document the following in SP1’s through SP7’s personnel record: · the number of hours per subject area for each training; and · the name of the trainer or instructor for each training. Corrective Action Ordered: Immediately upon receiving this order, you must maintain the following training information in each staff person’s personnel record: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. 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. 20. 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 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 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 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 20. b. The license holder failed to ensure that the staff person 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 20. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the staff person identified as designated coordinator and designated manager for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; · maintain documentation that the designated coordinator and designated manager has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3. You must maintain this documentation in your program’s records. Compliance with this order 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. 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
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