|
June 18, 2025 Kayla Peltier, Authorized Agent Beacon Specialized Living Minnesota Inc. 1355 Mendota Heights Road Suite 260 Mendota Heights, Minnesota 55120-1168 License Number: 1070450 (245D – HCBS) 1114368 (CRS – HCBS) Investigation Report Number: 202502833; 202503285 CORRECTION ORDER Dear Kayla Peltier: On May 19, 2025, a licensing investigation of Beacon Specialized Living Minnesota Inc., located at 7900 62 Avenue North, Brooklyn Park, 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 investigation, 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 investigation. 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 245D.04, subdivisions 2 and 3. Violation: For one of one person whose record was reviewed (P1), the license holder did not ensure the protection of the person’s rights in the services provided as required. a. The license holder implemented a restriction of P1’s rights in P1’s support plan addendum dated February 20, 2025, that restricted P1’s access to the refrigerator. The license holder failed to document the objective measures set as conditions for ending the restriction in P1’s record. b. During a site visit to P1’s home, DHS licensors observed that P1’s personal items were locked in a room that P1 did not have access to. The license holder did not ensure that P1 had access to their personal possessions, and did not have a documented restriction of this right. Corrective Action Ordered: Immediately upon receiving this order, you must ensure P1 has access to all personal items not identified as part of a rights restriction. Within 30 days of receiving this order, you must determine the objective measures set as conditions for ending P1’s restricted access to the refrigerator. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.11, subdivision 2, clause (7). Violation: For one person whose record was reviewed (P1), the license holder did not implement the incident reporting and review policy procedures as required. Between April 2, 2025, and May 21, 2025, P1 was involved in multiple behavioral incidents that required law enforcement intervention. The license holder failed to: · implement their incident reporting and review policy and procedures to protect the health and welfare of P1 and others; · conduct a review of incident reports for identification of incident patterns; and · implement corrective action as necessary to reduce occurrences and protect the health and safety of P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct a review of all incident reports regarding P1 from April 2, 2025, to current for identification of incident patterns and implementation of corrective action as necessary; · discuss with P1’s interdisciplinary team your findings; and · maintain evidence of the reviews in P1’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9544.0110, subpart C. Violation: For one person whose record was reviewed (P1), the license holder did not use the behavior intervention reporting form (BIRF) to report incidents as required by the commissioner. The license holder failed to use the BIRF to report a behavioral incident involving P1 that resulted in a call to 911 or law enforcement on the following dates: · April 2, 2025; · April 7, 2025; · April 16, 2025; · April 18, 2025; · April 22, 2025; · April 23, 2025; · April 26, 2025; · May 11, 2025; · May 15, 2025; · May 17, 2025; · May 18, 2025; and · May 19, 2025. Corrective Action Ordered: Immediately, you must use the behavior intervention report form required by the commissioner to report the behavior incidents which occurred on the above mentioned dates. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: For one person whose record was reviewed (P1), the license holder did not implement the emergency use of manual restraint policy and procedures as required. The license holder’s emergency use of manual restraint (EUMR) policy stated that staff would be trained to properly identify thresholds for implementing restrictive procedures. The license holder’s administrative staff reported to DHS licensors on May 19, 2025, that an emergency use of manual restraint would be implemented in “life or death situations.” Between April 2, 2025, and May 21, 2025, P1 was involved in multiple incidents in which P1’s behavior posed an imminent risk of physical harm to self or others. The license holder failed to implement their EUMR policy and procedures to protect the health and welfare of P1 and others. Corrective Action Ordered: Immediately, you must: · retrain all staff persons who work with P1 on how to properly identify thresholds for implementing restrictive procedures; · maintain documentation of the training in the staff person’s personnel records; and · submit evidence of the trainings to this licensor. Within 30 days of receiving this order, you must: · meet with P1, P1’s legal representative, P1’s case manager, and other members of the expanded support team to determine a plan for ensuring P1’s immediate safety when P1’s behavior poses an imminent risk of physical harm to self or others; · submit documentation of the plan to this licensor; · provide all staff persons with training to the plan; and · maintain documentation of the training in the staff persons’ personnel records. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at lacey.l.walsvik@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Lacey Walsvik Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Lacey Walsvik, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
|
