|
November 19, 2025 Susan Rosette, Authorized Agent Cardinal Comfort Care Cooperative 1313 Fairgrounds Road, suite 101 Two Harbors, Minnesota 55616 License Number: 1119610 (245D – HCBS) CORRECTION ORDER Dear Susan Rosette: On October 7, 2025, a licensing review of Cardinal Comfort Care Cooperative, located at 1313 Fairgrounds Road, Suite 101, Two Harbors, 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 2. Violation: For one of four persons whose record were reviewed (P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder provided multiple services to P2. The license holder did not develop an IAPP for P2 that included a statement of specific measures that would be taken to minimize the risk of abuse to P2 within the scope of each licensed service P2 received. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s IAPP to include a statement of measures that will be taken to minimize the risk of abuse to P2 within the scope of each licensed service P2 receives. Additionally, you must provide orientation on the updates to P2’s IAPP to all staff that provide direct support to P2. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide service recipient rights as required. The license holder did not provide P1 or P1’s legal representative with a written notice that identified the service recipient rights, and an explanation of those rights annually in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1 or P1’s legal representative with a written notice that identifies the service recipient rights, and an explanation of those rights. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. 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 provided P1 with individualized home supports with family training services. The license holder did not comply with the federal waiver plan when P1’s relative was hired by the license holder as staff person to provide direct support services to P1. P1’s relative no longer providers the individualized home supports to P1. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one person whose record was reviewed (P1), the license holder did not provide person-centered planning and service delivery as required. The license holder did not provide services in response to P1’s desired outcome. The license holder maintained information in P1’s record that documented P1 desired to have an outcome related to community involvement. The license holder did not develop an outcome consistent with P1’s desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan that documents the service outcomes and supports based on person-centered planning and P1’s desired outcome; and · document the supports and methods to be implemented to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not complete initial service planning for basic support services as required. a. The license holder did not review and revise P1’s preliminary support plan addendum within 60 calendar days of service initiation to document the respite services that would be provided including, how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. b. The license holder did not review and revise P3’s preliminary support plan addendum within 60 calendar days of service initiation to document the services that would be provided including, how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. The license holder initiated P3’s services on June 14, 2024. The license holder completed a review of P3’s preliminary support plan addendum on September 23, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P1’s and P3’s support plan addendum to document the services that will be provided including how, when, and by whom the services will be provided. Additionally, you must provide orientation to the updates to P1’s and P3’s support plan addendum to all staff that provide direct support to P1 and P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not meet initial service planning requirements as required. The license holder did not complete assessments that produced information about P2 that described the person’s overall strengths, functional skills, and abilities. Corrective Action Ordered: Within 30 days of receiving this order, you must complete assessments for P2 that describes P2’s overall strengths, functional skills, and abilities. 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 (P1), the license holder did not develop service outcomes and supports as required. The license holder did not document the following supports and methods to be implemented to support P1 and accomplish outcomes: · the methods or actions that would 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 were provided; o any equipment or materials required; and o techniques that were consistent whit the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the date by which progress towards accomplishing the outcome would be reviewed and evaluated; and · the names of the staff person or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receipt of this order, you must develop the information listed above in P1’s support plan addendum. On an ongoing basis, you must maintain compliance as required with this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet service plan review and evaluation as required. The license holder did not discuss how technology might be used to meet P1’s desired outcomes, including a summary of this discussion and a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made with P1, P1’s legal representative, and P1’s case manager at P1’s annual meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must meet with P1, P1’s legal representative and P1’s case manager to determine the information listed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Rules, chapter 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P3), the license holder did not evaluate positive support strategies as required. The license holder did not evaluate the identified positive support strategies with P3 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate P3’s positive support strategies to determine whether changes are needed, and if so, make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For four of four staff persons whose records were reviewed (SP1, SP2, SP3 and SP4), the license holder did not provide orientation training as required. a. The license holder did not provide SP1 with an orientation to the following within 60 calendar days of hire: · basic first aid; and · orientation to the license holder's emergency use of manual restraint policy and procedure, including their location and access, and staff responsibilities related to implementation of those policies. SP1 is no longer employed with this license holder. b. The license holder did not provide SP3 with an orientation to the following within 60 calendar days of hire: · basic first aid; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · orientation to the license holder's emergency use of manual restraint policy and procedure, including their location and access, and staff responsibilities related to implementation of those policies. SP3 received training on basic first aid on March 1, 2025, and received training on the strategies to minimize the risk of sexual violence on October 1, 2025. c. The license holder did not provide SP2 and SP4 with an orientation to the following within 60 calendar days of hire: · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support services 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; · 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: · SP2 and SP4 with an orientation to the training requirements identified above; and · SP3 with an orientation to the license holder’s emergency use of manual restraint policy and procedure, including their location and access, and staff responsibilities related to implementation of those policies. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs training as required. The license holder did not provide SP1 with the following training before having unsupervised direct contact with a person served by the program: · orientation to the individual service recipient needs; · the person’s support plan or support plan addendum; and · the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. SP1 is no longer employed with this license holder. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide annual training as required. 245A subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder did not provide SP3 with annual training on the following topics prior to or within the same month of the subsequent calendar year as required: · data privacy requirements according to 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; · sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons form maltreatment and reporting maltreatment; · the principles of person-centered services planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply 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; and · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP3 with the annual trainings documented above. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For four staff persons whose records were reviewed (SP1, SP2, SP3 and SP3), the license holder did not maintain personnel records as required. The license holder did not maintain documentation of staff training in SP1, SP2, SP3 and SP4’s personnel records that included date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Corrective Action Ordered: 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. Amber Nielsen, Home and Community-Based Services Licensor Licensing Division Office of Inspector General 651-431-3661
|
