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October 15, 2025 Aaron Fisk, Authorized Agent Catholic Charities In Home Program 911 Eighteenth Street North Saint Cloud, Minnesota 56303 License Number: 1070417 (245D – HCBS) License Investigation Report Numbers: 202500303, 202500826, 202502135 CORRECTION ORDER Dear Aaron Fisk: On August 19, 2025 and August 20, 2025, a licensing review and licensing investigation of Catholic Charities In Home Program, located at 157 Roosevelt Road, Suite 200, Saint Cloud, 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 two of sixteen persons whose records were reviewed (P9 and P10), the license holder did not complete an internal review of alleged or suspected maltreatment as required. The license holder did not complete an internal review for and incident involving P9 that occurred on January 12, 2025, and incidents involving P10 that occurred on January 25, 2025, and March 12, 2025, that included an evaluation of the following: · whether related policies and procedures were followed; · whether the policies and procedures were adequate; · whether there is a need for additional staff training; · whether the reported event is similar to past events with the vulnerable adults or the services involved; and · whether there is a need for corrective action by the license holder to protect the health and safety of vulnerable adults. Corrective Action Ordered: Within 30 days of receiving this order, you must complete internal reviews for the incidents referenced above. Based on the results of this review, you must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or the license holder, if any. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For one person whose record was reviewed (P3), the license holder did not develop an individual abuse prevention plan as required. The license holder did not conduct an individualized assessment of P3's susceptibility to abuse and document the specific actions the program would take to minimize the risk of abuse. The license holder maintained an IAPP for P3 dated July 16, 2025. P3’s IAPP did not include information about P3’s susceptibility to abuse that was consistent with information found elsewhere in P3’s support plan and support plan addendum. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P3’s IAPP to include all areas that P3 would be susceptible to abuse; · document the specific measures your program will take to minimize those risks for P3; and · ensure all staff persons providing direct support services to P3 receive an orientation to the updated IAPP. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated August 28, 2023; and · Order of Conditional License, dated June 12, 2025. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P4), the license holder did not maintain documentation of health needs as required. The license holder was assigned the responsibly of meeting P4’s health service needs, including the administration of a PRN psychotropic medication. The license holder did not maintain documentation on how P4’s health needs would be met, including a description of the procedures the license holder would follow in order to safely and correctly administer P4’s PRN psychotropic medication. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation on how P4’s health needs will be met, including a description of the procedures the license holder will follow in order to safely and correctly administer P4’s PRN psychotropic medication. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated December 21, 2022; · Correction Order dated August 28, 2023; · Correction Order dated March 25, 2024; · Correction order dated October 2, 2024; and · Order of Conditional License, dated June 12, 2025. 4. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not maintain information on psychotropic medications as required. The license holder was assigned the responsibility of medication administration for P2, including psychotropic medications. The license holder did not document a description of the target symptoms that each psychotropic medication was to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must document a description of the target symptoms that each psychotropic medication is to alleviate for P2. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated August 28, 2023; · Order of Conditional License, dated June 12, 2025. 5. Citation: Minnesota Statutes, section 245D.06, subdivision 1. Violation: For one person whose record was reviewed (P10), the license holder did not meet protection standards of incident response and reporting as required. Regarding licensing investigation report number 202500826, the license holder did not report an incident that occurred with P10 on January 25, 2025, to P10’s legal representative and P10’s case manager within 24 hours. The license holder later reported the incident to P10’s legal representative and P10’s case manager. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated August 28, 2023; and · Order of Conditional License dated June 12, 2025. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P9 and P10), the license holder did not provide service in response to the person’s identified supervision needs as required. a. Regarding licensing investigation report number 202500303, the license holder did not provide services in response to P9’s identified supervision needs as specified in P9’s support plan addendum, and in compliance with the requirements of this chapter and the federal waiver plan. On January 12, 2025, P9’s supervision needs were not met resulting in P9 eloping from the program. b. Regarding licensing investigation report number 202502135, the license holder did not provide services in response to P10’s identified supervision needs as specified in P10’s support plan addendum, and in compliance with the requirements of this chapter and the federal waiver plan. On March 12, 2025, P10’s supervision needs were not met resulting in P10 eloping from the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated December 21, 2022; · Correction Order dated August 28, 2023; · Correction Order dated May 21, 2025; and · Order of Conditional License dated June 12, 2025. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not conduct assessments as required. The license holder maintained a document titled “Support Plan Addendum for Intensive Services” for P3 that was dated July 16, 2025, that included the required assessments. The assessments conducted by the license holder included conflicting or incomplete information for P3: a. In one area of P3’s assessment, the license holder documented that staff would complete visual or auditory checks on P3 every 15 minutes. Another area of P3’s assessment, the license holder documented that staff would be in the same room as P3 at all times. b. In the assessments completed by the license holder on July 16, 2025, the license holder documented that there had been no attempts of elopement observed. An email from the license holder to P3’s support team on June 26th, 2025, stated that there had been an increase of attempted elopement by P3. c. In one area of P3’s assessment, the license holder documented that staff would remain within visual distance when P3 is eating. Another area of P3’s assessments, the license holder documented that staff would sit near P3 and between P3 and P3’s housemates while P3 is eating. d. Information was received from an interview with a staff person, in daily log notes, and other areas of P3’s support plan addendum that P3 has a history of exposing him/herself at home and at work. This information was not included by the license holder in the assessments. e. Information was received from an interview with a staff person and other areas of P3’s support plan addendum that P3 engages in self induced vomiting. This information was not included by the license holder in the assessments. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct the required assessments for P3 and ensure consistent and accurate information is included in the assessments; · provide P3’s support team an opportunity to review the completed assessments; and · ensure that all staff receive training on the assessments conducted for P3. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a licensing action that DHS issued on the following dates, you were previously found in violation of this same statue: · Correction Order dated August 28, 2023; and · Order of Conditional License, dated June 12, 2025. 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. Amber Nielsen, Home and Community-Based Services Licensor Licensing Division Office of Inspector General
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