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NOTICE: This Amended Correction Order corrects the address of the Authorized Agent and a punctuation error in citation ten. The original Correction Order dated May 2, 2025, must be destroyed. Date First Issued: May 2, 2025 Date Reissued: May 28, 2025 Arnold Kubei, Authorized Agent Home Sweet Home Minnesota 2056 Woodlane Drive Woodbury, Minnesota 55125 License Number: 1112301 (245D – HCBS) CORRECTION ORDER Dear Arnold Kubei, On March 19, 2025, a licensing review of Home Sweet Home, located at 2056 Woodlane Drive Woodbury, Minnesota 55125, 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 two persons whose records were reviewed (P2), the license holder did not provide orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults and program abuse prevention plan (PAPP) as required. a. The license holder failed to provide P2 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. P2’s service initiation date was August 1, 2023. P2 was provided orientation to the internal and external reporting procedures on November 1, 2023. b. The license holder failed to provide P2 with orientation to the PAPP within 24 hours of admission. The license holder provided orientation to the PAPP on November 1, 2023. 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. Violation: For one person whose records were reviewed (P1), the license holder did not meet the requirements for individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1 that included an individualized assessment of P1’s susceptibility of abuse and statements of the specific measures to be taken to minimize the risk of abuse. P1’s IAPP dated February 4, 2025, indicated that P1 was not susceptible to abuse. This assessment was not consistent with information maintained in P1’s record. Corrective Action Ordered: Within 60 days of receiving this order, you must review and revise P1’s IAPP to meet requirements of this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide the person a written notice that identified the service recipient rights and an explanation of those 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 a written notice that identified the service recipient rights and an explanation of those rights annually to P1. The license holder most recently provided P1 the notice in November 2023. b. The license holder failed to provide a written notice that identified the service recipient rights and an explanation of those rights to P2 within five working days of service initiation. P2’s service initiation date was August 1, 2023, and the service recipient rights were provided December 20, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 with written noticed that identifies the service recipient rights and an explanation of those rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not ensure the exercise and protection of the person’s rights in the services provided by the license holder and as authorized in the support plan. The license holder failed to exercise the protection-related rights of P1 and P2 which included the right to: · be treated with courtesy and respect and receive respectful treatment of the person’s property; · personal privacy, including the right to use the lock on the person’s bedroom or unit door; and · engage in chosen activities. The license holder maintained and enforced an “Integrated Community Supports Handbook” that: · prohibited the possession and/or use of cough syrup or mouth wash that contained alcohol · required random urinary analysis twice monthly; and · required weekly apartment inspections for all residents. Corrective Action Ordered: Immediately, you must exercise and protect all service recipient rights, and you must update the “Integrated Community Supports Handbook” to remove references to any restrictions included in the document. Additionally, you must train all staff and provide orientation to persons served on the updated “Integrated Community Supports Handbook.” On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.06, subdivision 1. Violation: For one person whose record was reviewed (P2), the license holder did not report and evaluate a serious injury as required. The license holder failed to report the serious injury to the Department of Human Services Licensing Division within 24 hours of discovery of the serious injury. P2 was involved in an incident that resulted in a serious injury discovered on November 11, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not complete assessments and service planning requirements for an intensive service as required.
a. The license holder failed to hold an initial planning meeting before providing 45 days of service to P1 and P2. P1’s service initiation was on November 17, 2023. P1’s initial planning meeting was held January 22, 2024. P2’s service initiation was August 1, 2023. P2’s initial planning meeting was held on November 1, 2023. b. The license holder failed to include a summary of the discussion of how technology might be used to meet P1 and P2’s desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order you must have a discussion with P1 and P2 about how technology might be used to meet their desired outcomes and summarize this discussion in P1 and P2’s support plan addendums. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. 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 as required. The license holder failed to document the following supports and methods to accomplish service outcomes for P1 and P2: · 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; · 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 · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1 and P2’s service outcomes and supports with the above-mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for service plan review and evaluation. The license holder failed to discuss with the P2 and their expanded support team, how technology might be used to meet P2's desired outcomes at least once per year. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P2 and P2’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; · service suspension and termination policy; · emergency use of manual restraints policy; and · data privacy. P2’s service initiation date was August 1, 2023. P2 received a copy of the policies and procedures on November 1, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must inform and provide copies of the above-mentioned policies and procedures to P2’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose records were reviewed (SP1), the license holder did not provide orientation training as required. The license holder failed to provide and ensure completion of orientation sufficient to create staff competency within 60 calendar days of hire for SP1 in the following areas: · responding to and reporting incidents as required under section 245D.06, subdivision 1; and following safety practices established by the license holder and as required in section 245D.06, subdivision 2; and · the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in these subdivisions. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one of three staff persons whose records were reviewed (SP1), the license holder did not orient staff to individual service recipient needs as required. The license holder failed to provide orientation to SP1 to the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve an understanding of the person as a unique individual and how to implement those plans, prior to unsupervised contact with the person served. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in these subdivisions. 12. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to evaluate the identified positive support strategies with P1 and P2 every 6 months. Corrective Action Ordered: You must evaluate the identified positive support strategies with P1 and P2 every 6 months. Based upon the result of 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 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 at 651-431-3661 as soon as possible. Jenna Johnson, Home and Community-Based Services Licensor Licensing Division Office of Inspector General
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