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Date issued: May 13, 2025 Date reissued: June 12, 2025 CERTIFIED MAIL Aaron Fisk, Authorized Agent Catholic Charities In Home Program 911 Eighteenth Street North Saint Cloud, Minnesota 56303-1203 License Numbers: 1070417 (Home and Community-Based Services) CRS: 1070419 (Home and Community-Based Services – Community Residential Setting) Mother Theresa Home CRS: 1070421 (Home and Community-Based Services – Community Residential Setting) Bethany Home License Investigation Report: 202409134 and 202408703 AMENDED ORDER OF CONDITIONAL LICENSE NOTICE: This Amended Order of Conditional License supersedes the Order of Conditional License dated May 13, 2025. This document is amended to correct the address of the Community Residential Setting (CRS), Mother Theresa Home, License No. 1070419, on pages 18 and 23. The original Order of Conditional License must be destroyed. Dear Aaron Fisk: The Department of Human Services (DHS) is placing your licenses to provide Home and Community-Based Services (HCBS), as well as your licenses to provide Community Residential Settings (CRS) at 101 10th Avenue North, Cold Spring, Minnesota and at 13 8th Avenue South, Cold Spring, Minnesota on conditional status for two years, beginning May 13, 2025. This means you must meet certain conditions to maintain your licenses, detailed below. This order applies to the service sites detailed in the “Applicability of Conditional License” section below. This order is based on your noncompliance with HCBS and CRS licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE Licensing Violations Determined on November 5-6, 2024 DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violation 1. Violation: The license holder did not ensure the designated coordinator and the designated manager (SP6-SP9) provided program management and oversight of the services provided by the license holder as required. a. See citations 2 through 23 regarding SP6 and SP7’s failure to: · provide oversight of the license holder's responsibilities assigned in the person's support plan and the support plan addendum; · take the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · provide 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 · evaluate 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 have been achieved according to the requirements in section 245D.07. b. See citations 2 through 23 regarding SP8 and SP9’s failure to: · maintain 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); · ensure the duties of the 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, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; · ensuring corrective action is taken when ordered by the commissioner and that the terms and conditions of the license and any variances are met; and · evaluate the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Statute Violated: Minnesota Statutes, section 245D.081. Service Recipient Violations 2. Violation: For two of six persons whose records were reviewed (P1 and P5), the license holder did not establish and enforce ongoing written individual abuse prevention plans as required. a. The license holder maintained an individual abuse prevention plan (IAPP) for P1, however, the license holder failed to contain an individualized assessment of P1’s risk of self-abuse. Additionally, the license holder failed to include a statement with the measures and specific actions the program would take to minimize P1’s risk of self-abuse in P1’s IAPP. b. The license holder failed to enforce P5’s individual abuse prevention plan (IAPP). The license holder maintained an IAPP for P5 in P5’s support plan addendum. P5’s IAPP documented that “Staff will ensure other medications are not in P5’s area.” During a licensing investigation on October 1, 2024, DHS licensors witnessed P3’s medications on the stairs of the home and accessible to P5. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 28, 2023. 3. Violation: For three persons whose records were reviewed (P1, P3 and P4), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder maintained a document in P1, P3 and P4’s record titled, “Policies Acknowledgement.” This acknowledgement documented that the license holder provided an explanation of rights to P1, P3, and P4, however, the license holder failed to provide a written notice that identified the service recipient rights annually in 2024. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. 4. Violation: For five persons whose records were reviewed (P1 through P5), the license holder did not ensure the protection and exercise of the person’s rights when the person resided in a residential site licensed according to chapter 245A, as required. a. The license holder failed to ensure the exercise and protection of P1 and P2’s right to receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site. During a site visit on November 4, 2024, DHS licensors observed the following at P1 and P2’s place of residence (CRS: 1070421): · food not properly stored and labeled in the refrigerator; · spoiled produce in the crisper drawer of the refrigerator; and · refrigerator was dirty and unkept b. The license holder failed to ensure the exercise and protection of P3, P4, and P5's following rights to: · receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site; and · receive services in 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 persons health or safety. During a site visit on November 4, 2024, DHS licensors observed the following at P3, P4, and P5's place of residence (CRS: 1070419): · feces smeared on the bedroom wall and along the hallway floor; and · black substance appearing to be mold or mildew on the ceiling in the basement. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 3. Repeat Violation: The license holder was cited for similar violations in a correction order dated August 28, 2023. 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet health service needs as required. The license holder was assigned responsibility for assisting P1 with scheduling and attending medical appointments in P1’s support plan and support plan addendum. The license holder failed to meet this health service need for P1 on September 10, 2024, when the license holder failed to take P1 to a scheduled dialysis appointment. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a). Repeat Violation: The license holder was cited for similar violations in a correction order dated August 28, 2023. 6. Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not maintain documentation of health service needs as required. a. The license holder was assigned responsibility for meeting P1’s health needs in the support plan addendum. The license holder failed to maintain documentation on how P1’s health needs would be met that included a description of the procedures the license holder would follow in order to provide medication administration, medication assistance and monitor health conditions according to written instructions from a licensed health professional. b. The license holder was assigned the responsibility of meeting P5’s health needs in the support plan and support plan addendum. P5 was prescribed a PRN psychotropic medication. The license holder failed to maintain documentation on how P5’s health needs would be met, including a description of the procedures the license holder would follow in order to safely administer P5’s psychotropic PRN medication. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). Repeat Violation: The license holder was cited for similar violations in the following licensing actions: · correction order dated August 28, 2023; and · correction order dated March 27, 2024 7. Violation: For five persons whose records were reviewed (P1 through P5), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for administering P1’s medications in P1’s support plan and support plan addendum. The license holder failed to implement medication administration procedures to ensure P1 took medications as prescribed in the following ways: · ensure the medication or treatment must be administered according to the license holder's medication administration policy and procedures as required under section 245D.11, subdivision 2, clause (3). o The license holder maintained a “Safe Medication Assistance and Administration Policy.” The policy documented that the license holder is responsible for coordinating medication refills. The license holder failed to coordinate refills for one of P1’s medications in June which resulted in P1 missing doses. o In a licensing investigation (report number 202409134), it was documented that P1 had multiple prescription medications found throughout P1’s bedroom. The license holder failed to ensure the proper storage and security of P1’s medications. · ensure the following information was documented in P1’s medication administration record (MAR): o instruction on when and to whom to report 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; o 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 · P1’s MAR indicated that P1 refused medications multiple times. The license holder failed to document when and to whom the report was made regarding those refusals. o notation of when a medication or treatment was started, administered, changed, or discontinued. · P1 had two new medications prescribed on May 16, 2024. The medications were transcribed on P1’s medication administration record (MAR), however, the license holder failed to include a notation of if the medication was ever administered. · P1 had a medication order documented on the MAR in October 2024, the license holder documented a line through it and documented “no longer needed.” The license holder failed to document if this medication was discontinued. · DHS licensors reviewed P1’s MARs from May 2024 to November 2024. There were multiple instances where the license holder failed to document a notation on the MAR if the medications were administered for all medications. b. The license holder was assigned responsibility for administering P2’s medications in P2’s support plan and support plan addendum. The license holder failed to implement medication administration procedures to ensure P2 took medications as prescribed in the following ways: · ensure the following information was documented in P2’s medication administration record (MAR): o 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, & when and to whom the report was made; and o notation of when a medication or treatment was started, administered, changed, or discontinued. · P2 had multiple medications and a treatment in P2’s medication bin that were not documented on the MAR; and · DHS licensors reviewed P2’s MARs from October 2024 to November 2024. There were multiple instances where the license holder failed to document a notation on the MAR if the medications or treatments were administered. c. The license holder was assigned responsibility for administering P3’s medications in P3’s support plan and support plan addendum. The license holder failed to implement medication administration procedures to ensure P3 took medications as prescribed in the following ways: · ensure the medication or treatment must be administered according to the license holder's medication administration policy and procedures as required under section 245D.11, subdivision 2, clause (3). o The license holder maintained a “Safe Medication Assistance and Administration” policy. The policy documented that the license holder is responsible for keeping all medications locked. During a licensing investigation visit on October 1, 2024, (report number 202402662) DHS licensors found P3’s medications on the stairs. The license holder failed to ensure proper storage and security of P3’s medications. · ensure the following information was documented in P3’s medication administration record (MAR): o information on any risks or other side effects that are reasonable to expect, and any contraindications to its use and that this information was readily available to all staff administering the medication; o the possible consequences if the medication or treatment is not taken or administered as directed; o instruction on when and to whom to report 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; o 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, & when and to whom the report was made; and o notation of when a medication or treatment was started, administered, changed, or discontinued. · DHS licensors reviewed P3’s MARs from May 2024 to November 2024. There were multiple instances where the license holder failed to document a notation on the MAR if the medications were administered for all medications. d. The license holder was assigned responsibility for administering P4’s medications in P4’s support plan and support plan addendum. The license holder failed to implement medication administration procedures to ensure P4 took medications as prescribed in the following ways: · ensure the medication or treatment must be administered according to the license holder's medication administration policy and procedures as required under section 245D.11, subdivision 2, clause (3). o P4 was prescribed Simethicone 125mg chew to be taken at 8am, 12pm, and bedtime, however, this was documented on P4’s MAR to be taken at 8am, 3pm, and bedtime. o P4 was prescribed psyllium seed powder, 5g by mouth in the morning, however, this was not documented on P4’s MAR. o P4 was prescribed Lorazepam .5mg for agitation to be taken as needed, however, this medication was not on P4’s MARs for the months of May 2024 to November 2024. o P4 was prescribed Buspirone 5mg to be taken at 8am, 2pm, and 8pm, however, this was documented on P4’s MAR to be taken at 8am, 3pm, and 8pm. o Regarding licensing investigation report 202408703, DHS licensors made unannounced visit on October 1, 2024. DHS licensors reviewed P4’s MAR. P4 had a medication listed on the MAR, scheduled to be administered twice daily for September 2024. The license holder failed to document if the medication was administered at all for the PM dose for the entire month. The license holder had a “post it” note on the MAR that documented, “why are we missing P4’s PM med.” · ensure the following information was documented in P4’s medication administration record (MAR): o information on any risks or other side effects that are reasonable to expect, and any contraindications to its use and that this information was readily available to all staff administering the medication; o the possible consequences if the medication or treatment is not taken or administered as directed; o instruction on when and to whom to report 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; o 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 o notation of when a medication or treatment was started, administered, changed, or discontinued. · DHS licensors reviewed P4’s MARs from July 2024 to November 2024. There were multiple instances where the license holder failed to document a notation on the MAR if the medications were administered for all medications. e. The license holder was assigned responsibility for administering P5’s medications in P5’s support plan and support plan addendum. The license holder failed to: · implement medication administration procedures to ensure the person takes medications as prescribed. o P5 had a new medication that was dispensed on October 8, 2024. The license holder failed to start the administration of this medication until November 1, 2024. · ensure the medication or treatment must be administered according to the license holder's medication administration policy and procedures as required under section 245D.11, subdivision 2, clause (3). o The license holder maintained a “Safe Medication Assistance and Administration” policy. The policy documented that the license holder is responsible for coordinating medication refills. The license holder failed to do so when P5’s PRN psychotropic medications were not refilled. · ensure the following information was documented in P5’s medication administration record (MAR): o the possible consequences if the medication or treatment is not taken or administered as directed; o instruction on when and to whom to report 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 the occurrence of possible adverse reactions to the medication or treatment. o 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 o notation of when a medication or treatment was started, administered, changed, or discontinued. · P5 had a PRN medication dose change on October 8, 2024. The license holder failed to transcribe the new physicians order onto the MAR as detailed in the license holders “Safe Medication Assistance and Administration Policy” and this subdivision. This medication was administered multiple times in the month of October and the license holder failed to include a notation of when it was administered. · P5 had a medication that was discontinued on June 5, 2024. The license holder failed to document a notation of when that medication was discontinued in the MAR. This medication was present on the MAR at the time of the review and there were multiple notations documenting that it had been administered throughout the months of June 2024 to November 2024. · DHS licensors reviewed P5’s MARs from May 2024 to November 2024. There were multiple instances where the license holder failed to document a notation on the MAR if the medications were administered for all medications. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2. Repeat Violation: The license holder was cited for similar violations in the following licensing actions: · Correction order dated August 28, 2023; and · Correction order dated March 27, 2024 8. Violation: For four persons whose records were reviewed (P1, P3, P4 and P5), the license holder did not review and report medication and treatment errors as required. a. The license holder failed to review P1, P3, P4 and P5’s medication administration record to ensure the information maintained in the MAR was current and was regularly reviewed to identify medication administration errors. Additionally, the license holder failed to develop and implement a plan to correct patterns of medication administration errors. b. The license holder failed to report the following to P1 and P5’s legal representatives and case managers: · any reports required under subdivision 2, paragraph (c), clause (4): · 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 · the occurrence of possible adverse reactions to the medication or treatment. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. Repeat Violation: The license holder was cited for similar violations in a correction order dated August 28, 2023. 9. Violation: For four persons whose records were reviewed (P1, P2, P3 and P4), the license holder did not meet the conditions for psychotropic medication use and monitoring as required. a. The license holder was assigned the responsibility of administration of P1’s psychotropic medications. The license holder was required to collect and report on medication and symptom related data and provide that monitoring data to the support team for review annually. The license holder failed to provide this report to P1’s support team annually in 2024. b. The license holder was assigned the responsibility of administration of P2, P3 and P4’s psychotropic medications. The license holder failed to document a description of the target symptoms that each of P2, P3 and P4’s psychotropic medications were intended to alleviate in P2, P3 and P4’s support plan addendum. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1. Repeat Violation: The license holder was cited for similar violations in a correction order dated August 28, 2023. 10. Violation: For one person whose record was reviewed (P5), the license holder did not meet the protection standards of incident response and reporting, as required. The license holder failed to report an incident that occurred on July 27, 2024, to P5’s legal representative and case manager within 24 hours of an incident that occurred with P5 while services were being provided. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 1. Repeat Violation: The license holder was cited for similar violations in a Correction order dated August 28, 2023. 11. Violation: For two persons whose records were reviewed (P2 and P4), the license holder did not meet the protection standards of safekeeping and handling of funds, as required. The license holder maintained an authorization from P2 and P4’s legal representative to assist with the safekeeping of P2 and P4’s funds, however, the license holder failed to survey P2 and P4’s case manager for preferences of the frequency of receiving a statement that itemized receipts and disbursements of funds. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 4. 12. Violation: For one person whose record was reviewed (P5), the license holder did not provide services in compliance with the requirements of this chapter and the federal waiver plans. Note: According to the Community-Bases Services Manual (CBSM), monitoring technology supervision is defined as the use of equipment to oversee, monitor, and supervise someone who receives waiver/AC services. It can help keep people safe and support independence. The equipment used may include alarms, sensors, cameras, and other devices. During a licensing visit (CRS: 1070419), DHS licensors witnessed the use of monitoring technology in P5’s bedroom. The license holder failed to comply with the federal waiver plan with monitoring technology usage in the following ways: · the license holder failed to store electronic video and audio recordings of participants for five days unless a participant or legal representative requests the recording be held longer based on: o a specific report of alleged maltreatment; and o the recording captures an incident or event of alleged maltreatment. · The license holder failed to ensure informed consent was maintained for the use of P5’s monitoring technology. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1. 13. Violation: For five persons whose records were reviewed (P1 through P5), the license holder did not provide person centered planning and service delivery as required. a. The license holder maintained a document in P5’s support plan titled, “Positive Support Strategies and Person-Centered Planning.” The assessment documented that P5 desired an outcome related sensory needs. While P5 did have an outcome established for a sensory program, the license holder failed to support P5 with that outcome based on the lack of data tracking documented for this outcome. The license holder failed to provide services in a manner that supported P5’s preferences and desired outcomes as specified in the support plan addendum, consistent with the principals of person-centered service planning and delivery. b. P5’s support plan addendum documented that P5 required 13 hours of one-to-one staffing and additional hours of shared staffing daily to support P5’s identified daily needs. The license holder failed to consistently schedule the shared staff as assigned in P5’s support plan in response to P5’s identified supervision needs. c. P1 through P5’s support plans documented that the license holder would only report 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 the occurrence of possible adverse reactions to the medication or treatment if it resulted in a serious injury. The license holder failed to assess each individuals’ unique needs, consistent with person centered planning, to determine how medication or treatment issues would be reported to P1 through P5’s legal representatives and case managers. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 28, 2023. 14. Violation: For one person whose record was reviewed (P5), the license holder did not meet the requirements for initial service planning as required. The license holder met with P5, P5’s legal guardian, P5’s case manager, and other members of P5’s support team within 45 days of service initiation, however, the license holder failed to determine the following based on information obtained from the assessments identified in paragraph (b), the person’s identified needs in the support plan, and the requirements in subdivision 4 and section 245D.07, subdivision 1a: · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; and · a discussion of how technology might be used to meet the P5's desired outcomes. The coordinated service and support plan or support plan addendum failed to include a summary of this discussion. The 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. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 28, 2023. 15. Violation: For one person whose record was reviewed (P4), the license holder did not meet the requirements for service plan review and evaluation as required. The license holder was required to provide P4, P4’s legal representative, and P4’s case manager with semiannual progress review reports. The license holder failed to identify rationale for changing, continuing, or discontinuing the implementation of support and methods identified in subdivision 4 in P4’s progress review report dated May 1, 2024. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 28, 2023. 16. 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. P2’s services were initiated on October 21, 2024. The license holder failed to provide P2’s case manager with the following policies that affect P2’s rights under section 245D.04 within 5 working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. Statute Violated: Minnesota Statues, section 245D.10, subdivision 4. Staffing Standards Violations 17. Violation: For three of nine staff persons whose records were reviewed (SP1, SP2 and SP4), the license holder did not provide annual training 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 the following annual training to SP1 in 2024: · 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 (HIPAA), and staff responsibilities related to complying with data privacy practices; and · 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; b. The license holder failed to provide the following annual training to SP2 in 2024: · 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 (HIPAA), and staff responsibilities related to complying with data privacy practices; and · other areas identified by the license holder in P3 and P4’s support plan addendums. c. The license holder failed to provide the following annual training to SP4 in 2024: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 245D.04; · 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. Statute Violated: Minnesota Statues, section 245D.09, subdivision 5. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 28, 2023. Record Requirements Violations 18. Violation: For four persons whose records were reviewed (P1, P2, P3 and P5), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes that are recorded by the program for P1, P2, P3 and P5: · DHS licensors reviewed P1’s daily log notes for July 2024 to November 2024. The license holder failed to document daily log notes for multiple days during the period reviewed. · DHS licensors reviewed P2’s daily log notes for October 2024 and November 2024. The license holder only had two log note entries in the period reviewed. · DHS licensors reviewed P3’s log notes for October 2024. The license holder failed to document daily log notes for 18 days. · The license holder maintained three outcomes for P3, two of the outcomes required data to be tracked at least once daily. DHS licensors reviewed P3’s outcome tracking sheets for July 2024, August 2024, and September 2024. The license holder failed to document progress on the outcome multiple times throughout the months reviewed. · DHS licensors reviewed P5’s daily log notes for September 2024 and October 2024. The license holder failed to document daily log notes for 8 days in the month of September and for most of days in October. · The license holder maintained two outcomes for P5, one of the outcomes required data to be tracked weekly and the other outcome required data to be tracked three times daily. DHS licensors reviewed P5’s outcome data tracking sheets, for September 2024, there was one day that the data tracking was documented, and for October 2024 there was no outcomes data tracking completed. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3. Repeat Violation: The license holder was cited for a similar violation in the following licensing actions: · Correction order dated August 28, 2023. · Correction order dated March 27, 2024 19. Violation: For one person whose record was reviewed (P5), the license holder did not ensure access to service recipient record as required. DHS licensors conducted a complaint investigation (investigation report number 202402662) on October 1, 2024, and reviewed P5’s support plan addendum. DHS licensors determined that the support plan addendum maintained in P5’s record was not current and was lacking in several areas that provided instruction to direct support persons. The license holder failed to ensure that staff providing services to the person had access to the relevant information required to safely support P5 including supervision and health needs. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 4. 20. Violation: For three staff persons whose records were reviewed (SP2, SP3 and SP4), the license holder did not maintain personnel records as required. The license holder failed to maintain documentation of the number of hours per subject area in SP2, SP3 and SP4’s personnel records. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 4. Repeat Violation: The license holder was cited for a similar violation in the following licensing actions: · Correction order dated April 28, 2023; and · Correction order dated August 28, 2023. Policy Requirement Violations 21. Violation: The license holder did not maintain policies and procedures for grievances as required. The license holder maintained a grievance policy, however, the license holder’s grievance policy failed to provide information that would allow the person to bring the complaint to the highest level of authority in the program if the grievance cannot be resolved by other staff members, and that provides the name, address, and telephone number of that person. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 2. 22. Violation: The license holder did not enforce policies and procedures regarding the use of universal precautions and sanitary practices as required. The license holder failed to enforce their “Universal Precautions and Sanitary Practices Policy” by failing to properly dispose of sharps. During a site visit conducted at CRS license number 1070421, DHS licensors observed a plastic bin that was labelled “med errors”. The bin mostly contained empty medication bubble packs and medication bubble packs that still contained medications. At the bottom of the bin there was a wearable diabetic sensor that was uncapped and appeared to have been used. The sensor was upside-down with the needle facing up towards top of the bin. When DHS licensors inquired about where the program’s sharps disposal container was located, program staff informed DHS licensors that the program did not have a sharps disposal container. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 1. 23. Violation: The license holder did not enforce policies and procedures regarding the safe medication assistance and administration as required. The license holder was responsible for administration of P1 through P5’s medications. The license holder maintained a policy titled, “Safe Medication and Administration Policy”. The license holder failed to enforce this policy in the following ways: · The policy documented that staff would contact the company nurse or appropriate medication professionals for instructions if staff notice missing signatures on the MAR. Staff would have 24 hours from the time they were contacted to return to the facility and initial the box, if they failed to return within 24 hours, the “documentation error” would be considered a violation of the policy and the staff person responsible would receive disciplinary action. Based on the volume of documentation errors discovered at the time of the review, and the lack of documentation of disciplinary action in the personnel records regarding these errors, it was evident that the license holder failed to enforce this policy. · The policy documented that staff would complete a medication discrepancy form when a medication is not administered as prescribed, place their initials in the MAR, circle the initials and write on back of the MAR the discrepancy. Based on the volume of medication discrepancies at the time of the review, and the lack of medication discrepancy forms, it was evidence that the license holder failed to enforce this policy. · The policy documented that if staff failed to follow the medication administration policy for the first time, it would result in disciplinary action, the second time would result in additional disciplinary action, and the third time would result in termination. Based on the volume of instances where the staff failed to follow the policy, and the lack of disciplinary action in the personnel records regarding violations to this policy, it was evident that the license holder failed to enforce this policy. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 2. Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite ongoing. If you fail to demonstrate substantial compliance with HCBS requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Nature, chronicity, or severity of violations and effective of violations(s) on health, safety, or rights of persons served by the program The Commissioner considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violations on the health, safety or rights of persons served by the program. Based on this analysis, your license will be placed on a conditional status. · Nature: DHS determined you were responsible for 23 licensing violations related to the health, safety, and rights of the persons served. · Chronicity: Your program received its license on January 1, 2014. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o March 10, 2021 Correction Order (licensing investigation 202000522) 1 violation o October 6, 2022 Fine Order for Background studies 2 violations o April 28, 2023 Correction Order (licensing investigation 202301294) 2 violations o August 28, 2023 Correction Order 16 violations o February 29, 2024 Correction Order (licensing investigation 202309234) 1 violation o March 25, 2024 Correction Order (licensing investigation 202309285) 4 violations o August 22, 2024 Substantiated Maltreatment Investigation (investigation 202403263) o November 14, 2024 Correction Order (licensing investigation 202402662) 2 violations o May 13, 2025 Order of Conditional License (this order) 23 Violations (14 repeat) o Between December 21, 2021 and November 1, 2024, Stearns County issued the following correction orders for your CRS program, Bethany Home, license number 1070421, located at 13 8th Avenue South, Cold Spring, Minnesota: · December 21, 2021 regarding Minnesota Statute 245D.21, Subdivision 2 and Minnesota Statute 245D.22, Subdivision 1. · April 4, 2022, regarding Minnesota Statute 245A.06, Subdivision 3 and Minnesota Statute 245D.22, Subdivision 1. · June 1, 2023, regarding Minnesota Statute 245D.21, Subdivision 2, Minnesota Statute 245D.22, Subdivision 1, Minnesota Statute 245D.24, Subdivision 3, Minnesota Statute 245D.26, Subdivision 1. · February 22, 2024, regarding Minnesota Statute 245D.22, Subdivision 1, Minnesota Statute 245D.26, Subdivision 2. · March 22, 2024, regarding and Minnesota Statute 245D.22, Subdivision 1. · March 25, 2024, regarding Minnesota Statute 245D.22, Subdivision 1. · May 28, 2024, regarding Minnesota Statute 245D.22, Subdivision 1 and Minnesota Statute 245D.22, Subdivision 5. · June 26, 2024, regarding Minnesota Statute 245D.22, Subdivision 1. · September 3, 2024, regarding Minnesota Statute 245D.22, Subdivision 1 and Minnesota Statute 245D.26, Subdivision 1. · November 1, 2024, regarding Minnesota Statute 245D.22, Subdivision 1, Minnesota Statute 245D.22, Subdivision 2, Minnesota Statute 245D.25, Subdivision 3. o Between March 31, 2023, and November 1, 2024, Stearns County issued the following corrections orders for your CRS program, Mother Theresa Home, license number 1070419, located at 101 10th Avenue North, Cold Spring, Minnesota: · March 31, 2023, regarding Minnesota Statute 245D.22, Subdivision 1 and 2, and Minnesota Statute 245D.26, Subdivision 1. · June 29, 2023, regarding Minnesota Statute 245D.22, Subdivision 1, Minnesota Statute 245D.25, Subdivision 1, Minnesota Statute 245D.26, Subdivision 1. · March 22, 2024, regarding Minnesota Statute 245D.22, Subdivision 1. · May 29, 2024, regarding Minnesota Statute 245A.65, Subdivision 2, Minnesota Statute 245D.25, Subdivision 1, Minnesota Statute 245D.22, Subdivision 5, Minnesota Statute 245D.24, Subdivision 3. · August 9, 2024, regarding Minnesota Statute 245D.22, Subdivision 1, Minnesota Statute 245D.22, Subdivision 2, Minnesota Statute 245D.24 Subdivision 2 and 3, Minnesota Statute 245D.25, Subdivision 3. · September 3, 2024, regarding Minnesota Statute 245A.65, Subdivision 1 and 2, Minnesota Statute 245D.22, Subdivision 1 and 2, and Minnesota Statute 245D.26, Subdivision 1. Requested reconsideration, however it was affirmed. · September 16, 2024, regarding Minnesota Statute 245D.22, Subdivision 1. · October 7, 2024, regarding Minnesota Statute 245D.22, Subdivision 1, and Minnesota Statute 245D.24, Subdivision 3. · November 1, regarding Minnesota Statute 245D.22, subdivision 1, Minnesota Statute 245D.25, subdivision 3 and Minnesota Statute 245D.26, subdivision 2. · Severity: Many of the violations involve your failure to properly document and review medication administration responsibilities, which could affect the health and safety of the persons served. You failed to document an individualized description of the procedures to provide medication administration; did not make notation when medications were administered; or conduct medication reviews to identify and correct medication errors. Failing to ensure service recipients receive the necessary health services and medication may have resulted in significant health complications from those who are dependent on the competent assistance of the license holder to ensure their health needs are met. You did not develop individual abuse prevention plans that included specific measures to be taken to reduce the risk of abuse to the person, which could negatively impact the health and safety of persons served. Individual abuse prevention plans provide staff with knowledge of potential risks and proactive or reactive strategies to reduce the risk. By not including specific measures to be taken in the individual abuse prevention plans, you did not ensure staff had knowledge of the specific measures to be taken to reduce the risk of abuse, thereby putting the health and safety of the persons you served at risk. License holders are required to ensure the exercise and protection of the rights of persons served by your program. You restricted persons rights to have a clean and safe home. Your failure to ensure the exercise and protection of the rights limited their ability to receive services in the least restrictive way and put persons health, safety and well-being at risk. The designated coordinators and designated managers failed to provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your program remains in compliance with licensing requirements. The requirement to identify and hire a qualified designated coordinator and designated manager is an essential function of a license holder due to the importance of these positions in providing program management and oversight of the services provided to persons served. These roles are responsible for understanding licensing requirements sufficient to ensure compliance throughout the program. As a result of your failure to ensure the designated coordinators and designated managers provided program coordination, evaluation and oversight, you were found in violation of the 28 citations described in this order. The license holder failed to provide orientation and annual training to direct support staff persons, including training on maltreatment reporting requirements. When direct support staff are not provided with orientation and annual training, staff may not be competent to provide services to persons and there is an increased risk of neglect or abuse to persons served by the program. As a result of your failure to train staff, the use of prohibited procedures for behavioral or therapeutic program to reduce or eliminate behavior, including manual restraint and seclusion, was implemented. Training staff is a critical part of ensuring persons served are kept safe and to ensure their rights are protected. The failure to provide staff training directly relates to health, safety, and well-being of persons served by the program. The license holder allowed a staff person to have direct contact after you were notified by DHS of the staff person’s disqualification. Allowing an individual to work without a cleared background study puts those served at risk of harm because DHS has evaluated the direct support staff’s criminal history and determined the staff is disqualified from providing direct support services. Further, the inability to remove disqualified individuals at the direction of DHS calls into question the program’s ability to follow the applicable laws and rules; to be able to operate a program; and to ensure the well-being of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide home and community-based services is placed on a conditional status. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the 28 violations (14 repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. The violations involved your lack of competence to ensure the duties and responsibilities of designated coordinators and designated managers. Due to the lack of oversight, you did not meet the responsibilities assigned in persons’ support plan addendums, including the health needs related to medication administration and the reporting of identified medication errors. Additionally, your lack of oversight allowed the rights of persons served to be restricted. The violations involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, therefore, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). This conditional license applies to the following licenses: 101 10th Avenue North, Cold Spring/1070419 and 13 8th Avenue South, Cold Spring/1070421 because they are not being operated in substantial compliance with applicable laws and rules. You did not maintain the interior and exterior of the community residential settings in good repair and in sanitary and safe condition. You did not correct building deterioration and safety hazards as ordered by the commissioner in previous actions. Additionally, you did not ensure that food was handled and store properly to prevent a threat to the health of persons served. These violations involved licenses 1070419 and 1070421 and were serious in nature, therefore, this conditional order applies to these two licenses. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (b). CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · Submit the name(s) and qualifications for the person(s) who will fulfill the duties and responsibilities of your designated coordinator and designated manager for DHS review and approval. It is your responsibility to ensure that these persons meet the necessary qualifications. Changes to these positions may not be made without prior notification and approval by DHS. 3. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. Within 60 days of receiving this order, you must: · Submit a written plan to DHS detailing how you will ensure the corrective action ordered in this order is completed. · Submit a written plan to DHS detailing how you will audit all participant and staff records for compliance with all applicable rules and statutes. 4. Within 60 days of receiving this order, you must: · Complete an audit of all participant and personnel records according to your written plan. · Submit the results of the audit to your DHS licensor. · Submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 5. During the duration of the conditional order, you must notify and receive approval from DHS and Stearns County Human Services Licensing prior to admitting new persons served to the two identified community residential settings, 1070419 and 1070421. The notification to your DHS and Stearns County Licensors must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service and documentation of compliance with term 1. 6. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 7. You may not add additional services to your HCBS license without prior approval from DHS for the duration of this conditional license. 8. Regarding the community residential setting 1070421-CRS, located at 13 8th Avenue South, Cold Spring, Minnesota, you must comply with the following conditional terms: · Any future instance of water damage, mold or biohazards discovered in the CRS, you must report to Stearns County you plan for remediation of the issue that must include a professional assessment and plan for restoration of the damaged areas of the CRS. · You must follow all recommendations of the professionals to prevent further water damage, mold contamination or biohazards at the CRS. · All staff providing direct care in the CRS, must complete an orientation training and annually thereafter, in the topic of food safety. This training should focus on receiving and storing food properly, sanitation of food-contact surfaces, utensils and equipment, proper storage of left-over food, cleaning food preparation appliances and cross contamination prevention practices for food. · Develop a written plan for food safety to be implemented at the CRS that includes: o assessing food dates in pantry, refrigerator, freezer; o purging spoiled, expired food; and o cleaning of food storage and preparation appliances · Develop a written plan for cleanliness to be implemented daily at the CRS that includes: o fecal and urine clean up, both inside and outside of the bathroom; o bathroom upkeep; o laundry and bedding; o floors, walls and all vents; o yard upkeep; o kitchen upkeep, including floors, counters, walls, food preparation areas and storage; o appliances and sinks; and o trash disposal. 9. Regarding the community residential setting 1070419-CRS, located at 101 10th Avenue North, Cold Spring, Minnesota, you must comply with the following conditional terms: · Assess and complete the restoration at the CRS to mitigate all biohazard materials, order and contamination. · Assess and complete the restoration at the CRS for all mold. · Assess and complete the restoration and resolution at the CRS for all water damage. · Any future instance of water damage, mold or biohazards discovered in the CRS, you must report to Stearns County you plan for remediation of the issue that must include a professional assessment and plan for restoration of the damaged areas of the CRS. · You must follow all recommendations of the professionals to prevent further water damage, mold contamination or biohazards at the CRS. · Implement a disposal system for adult incontinence products that is covered, lined and at minimum disposed from the CRS daily. · All staff providing direct care in the CRS, must complete an orientation training and annually thereafter, in the topic of food safety. This training should focus on receiving and storing food properly, sanitation of food-contact surfaces, utensils and equipment, proper storage of left-over food, cleaning food preparation appliances and cross contamination prevention practices for food. · Develop a written plan for food safety to be implemented at the CRS that includes: o assessing food dates in pantry, refrigerator, freezer; o purging spoiled, expired food; and o cleaning of food storage and preparation appliances · Develop a written plan for cleanliness to be implemented daily at the CRS that includes: o fecal and urine clean up, both inside and outside of the bathroom; o bathroom upkeep; o laundry and bedding; o floors, walls and all vents; o yard upkeep; o kitchen upkeep, including floors, counters, walls, food preparation areas and storage; o appliances and sinks; and o trash disposal. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: Commissioner, Department of Human Services ATTN: Amber Nielsen c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Submissions required as part of a corrective action ordered must be sent to your Stearns County licensor at: Stearns County Human Services ATTN: Susan Welle PO Box 1107 St. Cloud, MN 56302 YOUR RIGHT TO REQUEST RECONSIDERATION Your timeline to request reconsideration of the Order of Conditional License is based on the date of the original order. You did not request reconsideration. You cannot request reconsideration of this amended order. This is a final order. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community-Based Services are required to follow Minnesota 245A, 245C, 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Troy Goudy, HCBS Unit Supervisor, at 651-431-6541 or Tawnya Arueya, AFC/CRS Unit Supervisor at 651-201-5571 Sincerely,
Jason Flint, Assistant Director Licensing Division Office of Inspector General
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