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July 28, 2025 Richard Akwasi Green, Authorized Agent Mercy and Grace Care Inc. 1821 University Avenue West Suite 134 Saint Paul, Minnesota 55104 License Number: 1110415 (245D – HCBS) CORRECTION ORDER Dear Richard Akwasi Green: On July 17, 2025, a licensing review of Mercy and Grace Care LLC, located at 1821 University Avenue West Suite 134, Saint Paul, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one of two persons whose record was reviewed (P2), 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. P2 was admitted to the program on March 17, 2025. The license holder did not provide P2 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder provided this orientation to P2 on March 28, 2025. 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 two person whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder did not develop an IAPP for P1 as part of the initial individual program plan. P1’s services were initiated on October 1, 2024. The license holder developed an IAPP for P1 on November 4, 2024. Additionally, the license holder assessed that P1 was vulnerable to physical abuse. The license holder did not include in P1’s IAPP a statement of measures, that included specific actions, that would be taken to minimize the risk of abuse to P1 in this area. b. The license holder did not develop an IAPP for P2 as part of the initial individual program plan. P2’s services were initiated on March 17, 2025. The license holder developed an IAPP for P2 on March 28, 2025. Additionally, the license holder assessed that P2 was vulnerable to physical abuse. The license holder did not include in P2’s IAPP a statement of measures, that included specific actions, that would be taken to minimize the risk of abuse to P2 in this area. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P1’s and P2’s IAPP to include a statement of measures, including specific actions, that will be taken to minimize the risk of abuse to P1 and P2 in the area of physical abuse. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the service recipient rights as required. a. The license holder did not provide P1 with a written notice that identified the service recipient rights, and an explanation of those rights within five working days of service initiation. P1’s services were initiated on October 1, 2024. The license holder provided P1 with the service recipient rights on November 4, 2024. b. The license holder did not provide P2 with a written notice that identified the service recipient rights, and an explanation of those rights within five working days of service initiation. P2’s services were initiated on March 17, 2025. The license holder provided P2 with the service recipient rights on March 28, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not maintain a service recipient record as required. a. The license holder did not maintain a signed statement authorizing the license holder to act in a medical emergency for P1. b. The license holder did not maintain progress or daily log notes for P1 and P2 that were recorded by the program. Corrective Action Ordered: Immediately upon receiving this order, you must: · begin maintaining progress or daily log notes for P1 P2; and · maintain a signed statement authorizing the license holder to act in a medical emergency for P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4 and Minnesota Rules, part 9544.0080, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not provide policies and procedures as required. The license holder did not inform P2 and P2’s case manager of the policies and procedures affecting a person’s rights, and provide copies of those policies and procedures within five working days of service initiation. P2’s services were initiated on March 17, 2025. The license holder provided the required policies and procedures to P2 on March 28, 2025, and to P2’s case manager on March 31, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate positive support strategies as required. The license holder did not incorporate positive support strategies in writing to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Immediately, you must incorporate positive support strategies into P1’s and P2’s existing support plan addendum. Additionally, the positive support strategies must be evaluated at least every six months with P1 and P2 to determine whether changes are needed, and if so, make appropriate changes. You must provide orientation on the updates to P1’s and P2’s support plan addendum to all staff that provide direct support to P1 and P2. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. The license holder did not provide the following orientation training to SP1 and SP2 within 60 days of hire: · how to complete specific job functions, including responding to and reporting incidents as required under section 245D.05, subdivision 1; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide SP1 and SP2 with the training listed above. On an ongoing basis, you must maintain compliance as required with this subdivision. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide the following orientation to SP1 and SP2 before having unsupervised direct contact with a person served by the program: · 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 and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide the orientation listed above to SP1 and SP2 for each service recipient that SP1 and SP2 provides direct support services to. On an ongoing basis, you must maintain compliance as required with this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP1 and SP2 that included the date of the employee's first supervised and unsupervised direct contact with a person served by the program. Corrective Action: 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 as soon as possible. Robert Romani, HCBS Licensor Licensing Division Office of Inspector General 651-431-3658
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