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August 19, 2025 Bradley Eckel, Authorized Agent Peterson Colonial Homes, Inc. Home 1 4723 Nygaard Road Brookston, Minnesota 55711 License Number: 1076387(245D – HCBS) CORRECTION ORDER Dear Bradley Eckel: On August 6, 2025, a licensing review of Peterson Colonial Homes, Inc. Home 1, located at 4866 Highway 31, Brookston, 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 record was reviewed (P3), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours as required. The license holder did not provide P3 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P3 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment and maintain documentation of this orientation in P3’s service recipient record as required in section 245D.095, subdivision 3, paragraph (b). On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not establish and enforce individual abuse prevention plans 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 did not include statements of measures that included specific actions the program would take to minimize the identified risk of abuse within the scope of the licensed service in P3’s IAPP. b. The license holder did not review and revise P1’s, P2’s, and P3’s individual abuse prevention plan (IAPP) with the interdisciplinary team annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · revise P1’s and P3’s IAPPs to include specific actions the program would take to minimize the identified risks of abuse within the scope of the licensed services; · review P1’s, P2’s, and P3’s revised IAPPs with their interdisciplinary teams and maintain documentation of this review in their records; and · provide orientation on the updates to P1’s, P2’s, and P3’s IAPPs to all staff that provide direct support to P1, P2, and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not provide the service recipient rights as required. a. The license holder did not provide P1, P2 and P3 with a written notice that identified the service recipient rights, and an explanation of those rights annually. b. The license holder did not provide P3 with a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1, P2 and P3 with a written notice that identified the service recipient rights, and an explanation of those rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not safekeep funds as required. The license holder did not obtain written authorization from P2 and P2’s case manager to assist with the safekeeping of P2’s funds annually in 2023, 2024, and 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P2 and P2’s case manager to assist with the safekeeping of P2’s funds; · document and implement the preferences of P2 and P2’s case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds; and · update P2’s support plan addendum to include the license holder’s responsibilities for safekeeping of funds. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1.
Violation: For one person whose record was reviewed (P2), the license holder did not provide positive support services compliant with the requirements of this chapter and the federal waiver plans. The Community-Based Services Manual indicated that license holder’s providing Positive Support Services must develop a positive behavior support plan to teach P2 an alternative, positive behavior that would result in an increase in P2’s quality of life and decrease of the challenging behavior. The license holder did not develop or maintain a positive behavior support plan, therefore the license holder failed to comply with the federal waiver plan while providing Positive Support Services to P2.
Corrective Action Ordered: Within 30 days of receiving this order, you must comply with the requirements for Positive Support Services as indicated in the Community-Based Services Manual. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not complete service planning for basic supports as required. The license holder did not participate in service planning and support team meetings for P1, P2, and P3 annually as required in P1’s, P2’s, and P3’s support plan with their support team or expanded support team. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P1’s, P2’s and P3’s support team or expanded support team. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 3. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide written reports as required. The license holder did not provide written reports to the expanded support team annually regarding P1’s, P2’s, and P3’s progress or status as assigned in P1’s, P2’s, P3’s support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1’s, P2’s, and P3’s expanded support team with a written progress or status report. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not maintain service recipient records as required. The license holder did not record progress or daily log notes for P2 while providing positive support services. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not inform and provide policies and procedures as required. The license holder did not inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P3 and P3’s case manager 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 30 days of receiving this order, you must provide P3 and P3’s case manager with the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate with P1, P2 and P3 whether the identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate with P2 the identified positive support strategies and document the evaluation in P2’s service recipient records; 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. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not provide orientation as required. The license holder did not provide SP1 orientation in the following areas within 60 calendar days of hire: · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures; · 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; · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for 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. SP1 was provided this training in May 2025; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. SP1 was provided this training in May 2025; · 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; · basic first aid; 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 with the above-mentioned trainings that have not yet been provided. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), 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 did not provide SP1 with annual training in 2024 on data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices. b. The license holder did not provide SP2 with annual training in 2022, 2023, and 2024 on the following topics: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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; · 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; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. The license holder did not provide SP2 with annual training in 2023 and 2025 on the following topics: · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for 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. SP2 was provided this training in June 2022, March 2024, and May 2025; and · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person. SP2 was provided this training in April 2022, March 2024, and May 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with the above-mentioned trainings. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: The license holder did not establish and maintain policies and procedures related to the internal reporting of alleged or suspected maltreatment. The license holder did not establish policies and procedures related to the internal reporting of alleged or suspected maltreatment that identified the primary and secondary person or position to whom internal reports may be made and the primary and secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5. Corrective Action Ordered: Within 30 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 14. Citation: Minnesota Statutes, section 245D.11, subdivision 4. Violation: The license holder did not establish and maintain policies and procedures related to admission criteria as required. The license holder did not establish policies and procedures for admission criteria that identified the criteria to be applied in determining whether the license holder can develop services to meet the needs specified in the person's support plan. Corrective Action Ordered: Within 30 days of receiving this order, you must establish and implement the above-stated policy to be in compliance with statutory requirements. On an ongoing basis, you must establish and enforce policies and procedures as required in this chapter. 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. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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