|
August 14, 2025 J Vang, Authorized Agent Care Plus PCA Inc 1299 Arcade Street Suite 100 St. Paul, Minnesota 55106 License Number: 1107814 (245D – HCBS) CORRECTION ORDER Dear J Vang: On June 9, 2025, a licensing review of Care Plus PCA located at 1299 Arcade Street, St. 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 four persons whose records were reviewed (P1), the license holder did not provide an orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder failed to provide P1 with an orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment within 24 hours of admission.
Corrective Action Ordered: Within 60 days of receiving this order, you must provide P1 with an orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a). Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder did not maintain an internal reporting policy that identified a secondary person or position to whom internal reports could be made. The license holder had listed an employee who no longer worked for the license holder.
Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and update your policy and procedure on maltreatment of vulnerable adults to include a primary and secondary person that are currently involved with the program; · provide notice to all persons served and legal representatives as applicable of the updated policy; and · provide notice to all staff of the updated policy. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, 245A.65, subdivision 2. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not develop individual abuse prevention plans (IAPP) 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 develop an IAPP for P1, P2, and P4 that included a statement of measures that would be taken to minimize the risk of abuse to P1, P2, and P4 within the scope of licensed services. b. The license holder failed to develop an accurate IAPP for P3. The license holder maintained an IAPP for P3 that indicated P3 had no vulnerabilities to abuse, including sexual abuse, physical abuse, self abuse, and financial exploitation; however, this was not consistent with information documented elsewhere in P3’s plan. P3’s addendum included information that would indicate vulnerability in the aforementioned areas. c. The license holder failed to review P2 and P3’s IAPP at least annually. P2’s IAPP was developed on March 1, 2023, and was reviewed on December 20, 2024. P3’s IAPP was developed on May 15, 2024. As of the licensing review on June 9, 2025, P3’s IAPP had not been reviewed. Corrective Action Ordered: Within 60 days of receiving this order you must: · revise the IAPP’s for P1-P4 to include the information that meets the requirements of this section; · review IAPP’s for P1-P4 with the person, their legal representatives, if applicable, and their case manager; · conduct an audit of all service recipient records to ensure each person’s IAPP includes an individualized assessment of their susceptibility of abuse, the specific measures to be taken to minimize the risk of abuse, and that the IAPP has been reviewed with individual’s support team in the previous twelve months; · review and revise any person’s IAPP that was determined by your audit to not be in compliance with 245A.65, subdivision 2; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not provide a written notice that identified the service recipient rights as required. a. The license holder failed to provide P1 or P1’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. b. The license holder failed to provide P2 with a written notice that identified the service recipient rights and an explanation of those rights annually in 2024. The license holder provided P2 with a written notice on March 1, 2023, and December 20, 2024. c. The license holder failed to provide P3 written notice that identified the service recipient rights annually in 2025. The license holder most recently provided P3 with a written notice on May 15, 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide P1 or P1’s legal representative with the service recipient rights; · provide P3 and P3’s case manager with written notice that identifies the service recipient rights; and · maintain a copy of receipt of the service recipient rights that were provided. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not meet health service needs as required. The license holder failed to maintain documentation on how P3’s health needs would be met, including a description of the procedures to provide medication assistance. Corrective Action Ordered: Within 60 days of receiving this order, you must: · update P3’s support plan addendum to include the information required by this subdivision; · provide training to staff working with P3 on the revised support plan addendum; and · maintain documentation of the training provided to staff. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not develop, document, and implement an emergency use of manual restraints (EUMR) policy and procedures as required. The license holder maintained an EUMR allowed policy, as well as, an EUMR not allowed policy. As a result of having both policies, the licensor holder failed to provide a clear description of the types of manual restraints the license holder allowed staff to use on an emergency basis, if any. Corrective Action Ordered: Within 60 days of receiving this order, you must: · select an EUMR policy that will be used for your agency; · remove any other EUMR policies from your records; · ensure that staff, persons served, and legal representatives are notified of your EUMR policy in accordance with 245D.10, subdivision 4. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not comply with the provision of services as required. The license holder failed to comply with the federal waiver plan when P1’s relative was hired by the license holder as a staff person to provide P1’s individualized home supports with family training service. According to the Community-Based Services Manual, individualized home supports (IHS) with family training cannot be provided by a relative. Corrective Action Ordered: Immediately, upon receiving this order, you must comply with the provision of services according to the requirements of this chapter and the federal waiver plans. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide services in response to the person’s identified needs, interests and preferences as required. The license holder provided multiple services to P1 and P2. The license holder failed to ensure that P1’s and P2’s support plan addendums identified what is important to P1 and P2 as well as what is important for P1 and P2, including preferences for when, how and by whom direct support service is provided. Corrective Action Ordered: Within 60 days of receiving this order, you must update the service plans for P1 and P2, to include the information required by this statute. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not complete initial service planning and review for intensive services as required. The license holder failed to complete assessments, within the scope of services, in the following areas before providing 45 days of service to P1: · the ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of P1 or others. The license holder failed to hold an initial planning meeting with P1, P1’s legal representative, and P1’s case manager before providing 45 days of service to determine the following for P1: · the scope of services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and supports necessary to accomplish the person’s desired outcomes; · the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · 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 relations with other persons of the person’s choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and · a discussion of how technology might be used to meet the person’s desired outcomes. Corrective Action Ordered: Within 60 days of receiving this order, you must: · meet with P1, P1’s legal representative, and P1’s case manager to assess and determine the above-mentioned topics; · document the results of the assessment and discussion in P1’s service recipient record; · provide training on the updated record to all staff working with P1; and · maintain documentation of the training provided to staff. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not document service outcomes and supports as required. The license holder failed to document supports and methods to be implemented to support P1 to accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional well-being, including: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes 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 60 days of receiving this order, you must: · document the supports and methods detailed above in P1’s support plan addendum; and · submit to and obtain dated signatures from P1, P1’s legal representative, and P1’s case manager to document completion and approval of the support plan addendum. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P4), the license holder did not complete ongoing reviews as required. The license holder failed to meet with P4’s case manager at least once per year to determine whether changes are needed to the service plan based on the assessment information or other information provided by the support team or expanded support team. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation training as required. The license holder failed to provide SP1-SP3 with an orientation to the following topics within 60 days of hire: · 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 receiving this order, you must provide SP1-SP3 with an orientation and training to the topics listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide annual training as required. a. The license holder failed to provide SP1 and SP3 annual training in basic first aid. The license holder last provided SP1 orientation training in basic first aid in August 2023. The license holder last provided SP3 orientation training in basic first aid in September 2022. b. The license holder failed to provide SP3 the following required annual training in 2024: · data privacy requirements according to 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; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; and · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3. The license holder provided SP3 with training in the above areas most recently in October 2023. Corrective Action Ordered: Within 30 days of receiving this order you must provide the above mentioned trainings to SP1 and SP3. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For four persons whose records were reviewed (P1-P4), 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 in the service recipient records for P1, P2, P3, and P4. Corrective Action Ordered: Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not maintain personnel records as required. a. The license holder did not maintain documentation in SP1’s personnel record of annual training including the number of hours per subject area and the name of the trainer or instructor for the following training topics: · data privacy; · service recipient rights; · maltreatment reporting and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · principals of person-centered planning; · the safe and correct use of manual restraint; · staff responsibilities related to prohibited procedures under 245D.06, subdivision 5; · basic first aid; and · strategies to minimize the risk of sexual violence. b. The license holder did not maintain documentation in SP3’s personnel record of the number of hours per subject area for SP3’s orientation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide copies of policies and procedures as required. a. The license holder failed to inform P1’s legal representative and P1’s case manager of the following policies and procedures affecting a person’s rights under 245D.04 and provide copies within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; and · data privacy requirements. b. The license holder failed to inform the case managers for P2, P3, and P4 of the following policies and procedures affecting a person’s rights under 245D.04 and provide copies of those policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; and · emergency use of manual restraints policy and procedure. Corrective Action Ordered: Within 60 days of receiving this order, you must provide the above-mentioned policies and procedures to P1’s legal representative, P1’s case manager, P2’s case manager, P3’s case manager, and P4’s case manager. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required. 17. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not implement or evaluate positive support strategies as required. a. The license holder did not incorporate positive support strategies for P3 and P4 in writing to an existing treatment, service, or other individual plan required of the license holder. b. The license holder failed to evaluate identified positive support strategies with P1 and P2, at least every six months. Corrective Action Ordered: Within 60 days of receiving this order, you must: · incorporate positive support strategies for P3 and P4 in writing to their individual plans; · evaluate identified positive support strategies with P1-P4 at least every six months; and · based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and if so, make appropriate changes. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight.
a. The license holder failed to ensure that the designated coordinator (SP4), provided supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07.
a. The license holder failed to ensure that the designated manager (SP6) provided program management and oversight of the services provided by the license holder that include: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · evaluation of satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person’s rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 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 · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements.
See citations one through seventeen for the designated coordinator and designated manager’s failure to provide the above stated requirements.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the staff person(s) identified as designated coordinator and designated manager for the program understands and has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and 3; and · maintain a signed document that the designated coordinator(s) and designated manager(s) have acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivisions 2 and 3 in your program’s records. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. Compliance with this order will be reviewed onsite at an upcoming compliance monitoring visit. On an ongoing basis, you must maintain compliance as required in this subdivision. 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
|
