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August 14, 2025 Cassandra Jackson, Authorized Agent Quality of Life Home Care Services 235 6th Street East STE 500 Saint Paul, Minnesota, 55101 License Number: 1100107 (245D – HCBS) CORRECTION ORDER Dear Cassandra Jackson: On June 24, 2025, a licensing review of Quality of Life Home Care Services, located at 235 6th Street East STE 500, 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 three persons whose records were 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. The license holder initiated P2’s services on July 14, 2023. The license holder did not provide P2 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder provided this orientation on January 8, 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 persons whose record was reviewed (P1 and P2), the license holder did not develop and review an individual abuse prevention plan as required. 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 did not review P1’s individual abuse prevention plan annually in 2024 with P1’s interdisciplinary team. The only individual abuse prevention plan maintained in P1’s support plan addendum was dated January 17, 2025. Additionally, the license holder assessed P1 to be susceptible to physical abuse, self-abuse, and financial abuse. The license holder did not include a statement of the specific measures the program would take to minimize the risk of abuse within the scope of services. b. The license holder did not develop an individual abuse prevention plan for P2 as part of the initial individual program plan or service plan prior to or upon service initiation. The license holder initiated P2’s services on July 14, 2023, and developed P2’s individual abuse prevention plan on March 4, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must · review and revise P1’s individual abuse prevention plan to include the information listed above; · review P1’s individual abuse prevention plan with P1’s interdisciplinary team; and · maintain documentation of this review in P1’s service recipient record. 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 written notice that identified the service recipient rights and an explanation of those 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 and annually. The license holder initiated P1’s services on May 5, 2023. The license holder provided P1 with the written notice on June 1, 2023 and January 17, 2025. b. The license holder did not provide P2 with a written notice of the service recipient rights and an explanation of the rights within five working days of service initiation and annually. The license holder initiated P2’s services on July 14, 2023. The license holder initiated a second service for P2 in August 2024. The license holder only provided P2 with a written notice on January 8, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet service planning requirements. a. The license holder initiated P1’s services on May 5, 2023, and developed P1’s preliminary support plan addendum on January 17, 2025. The license holder did not complete a support plan addendum within 15 calendar days of P1’s service initiation. Additionally, the license holder did not review, and revise as needed, P1’s preliminary support plan addendum to document the services to be provided including how, when, and by whom services would be provided, and the person responsible for delivery and coordination of services. b. The license holder provided multiple services to P2. The license holder did not ensure that P2’s support plan addendum identified each service provided, when services were provided, and the license holder’s responsibility for oversight and coordination of services. c. The license holder initiated three services for P2 on July 14, 2023 and maintained a support plan addendum dated February 28, 2024. The license holder did not complete a preliminary support plan addendum based on the support plan within 15 calendar days of service initiation for P2. The license holder initiated an additional service for P2 in August 2024 and did not develop a preliminary support plan. Additionally, the license holder did not review and revise, as needed, P2’s support plan addendum within 60 calendar days of service initiation for the service the license holder initiated on July 14, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must document each service that will be provided for P1 and P2, including: · how, when, and by whom services will be provided; and · the person responsible for overseeing the delivery and coordination of services. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (a), (b). Violation: For one person whose record was reviewed (P3), the license holder did not complete initial service planning for an intensive support service as required. The license holder initiated P3’s services on November 7, 2024 and the license holder developed a support plan addendum for P3 on December 31, 2024. The license holder did not complete a preliminary support plan addendum for P3 within 15 calendar days of service initiation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P3), the license holder did not hold an initial service planning meeting for an intensive support service as required. The license holder did not meet with P3, P3’s legal representative, case manager, and other members of the support team within 45 days of service initiation to determine the following: · the person’s desired outcomes and the 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 strengthen personal relationships with other persons of the person’s choice 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. The coordinated service and support plan or support plan addendum must include a summary of this discussion. This 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · meet with P3, P3’s legal representative, case manager, and members of the support team to determine the items mentioned above; and · document the meeting, including what was determined at the meeting in P3’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not meet the requirements for service outcomes and supports. The license holder did not develop a service plan for P3 that documented the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan for P3 that includes: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning and evaluation requirements. P2’s support plan addendum developed by the license holder dated February 28, 2024, and January 8, 2025, required quarterly service plan meetings and written reports. The license holder did not participate in quarterly service plan review meetings or provide quarterly written reports as assigned. Corrective Action Ordered: Within 30 days of receiving this order, you must: · hold a service plan review meeting with P2, P2’s case manager and members of P2’s support team. You must document the meeting, including the date the meeting was held, who attended the meeting, and what was discussed in P2’s support plan addendum; and · discuss with P2, P2’s case manager and members of the support team the preferred timeline for service plan review meetings and reports. You must implement the timelines for meetings and reports determined by P2’s support team and maintain documentation of these timelines in P2’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statues, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder did not inform and provide copies of the following policies and procedures that affect a persons rights under section 245D.04 to P1, P2 and P3 and their case managers within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy. The license holder initiated P1’s services on May 5, 2023, and provided the policies to P1 on January 17, 2025. The license holder initiated P2’s services on July 14, 2023, and provided the policies to P2 on January 8, 2025. The license holder initiated P3’s services on November 7, 2024, and provided the policies to P3’s legal representative on December 11, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1’s, P2’s and P3’s case managers with copies of the above-mentioned policies and procedures. You must maintain documentation that these policies and procedures were provided in P1’s, P2’s and P3’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate with P2 and P3 the identified positive support strategies at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P2 and P3 whether the identified positive support strategies currently meet the standards in subpart 2 to determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. Additionally, you must maintain documentation of this evaluation in P1’s and P2’s service recipient records. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not maintain service recipient records as required. a. The license holder did not maintain documentation of P1’s orientation to the license holder’s maltreatment reporting policies and procedures according to 245A.065, subdivision 1, paragraph (c). b. The license holder reported to DHS that they discarded the “old records.” The license holder did not protect service recipient records against loss according to the requirements in sections 13.01 to 13.10 and 13.46 when they discarded person served records. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining the service recipient records of all persons who receive services from your program on the premises where the services are provided or coordinated. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. The license holder did not provide SP2 with the following training within 60 days of hire: · the license holder’s policy and procedure for responding to, reporting and reviewing incidents; and · basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with the above-mentioned trainings. You must maintain documentation of the trainings provided in SP2’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation training on individual service recipient needs as required. The license holder did not document that the license holder provided instruction to SP2 on the person’s support plan or support plan addendum as it relates to the responsibilities related 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. DHS licensors could not determine SP2 received this training prior to having direct contact with persons served by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with the above-mentioned training. You must maintain documentation of the training provided in SP2’s personnel record. 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 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. Kate Spenger, Human Services Licensor Licensing Division Office of Inspector General 651-431-5757
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