|
February 23, 2026 Jody Miller, Authorized Agent Lutheran Social Services 2485 Como Avenue Saint Paul, Minnesota 55108 License Number: 1069963 (245D – Home and Community-Based Services) Investigation Report Number: 202510442 CORRECTION ORDER Dear Jody Miller: On February 23, 2026, a licensing complaint investigation of Lutheran Social Services, located at 2485 Como Avenue, 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 complaint investigation, 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 245D.04, subdivision 3. Violation: For one of one person whose record was reviewed (P1) the license holder did not ensure the exercise and protection of the person’s rights as required. The license holder did not ensure the exercise and protection of P1’s right to be treated with courtesy and respect when a staff person documented in P1’s log notes that another staff person told P1 “in a demanding tone” that they “will not be coming back” [into P1’s room] to assist him because [staff] was annoyed.” Corrective Action Ordered: Immediately upon receiving this order, you must begin providing services to P1 in a courteous and respectful manner. Within 30 days of receiving this order, you must: · provide training to all staff persons who provide direct support services to P1 on courteous and respectful service delivery; · maintain documentation of this training in the staff persons’ personnel records; and · submit documentation that this training was provided to the staff persons to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not meet health service needs, as required. a. The license holder was assigned the responsibility of assisting P1 with P1’s range of motion exercises in P1’s support plan addendum. P1’s range of motion exercises were to be completed twice daily. On October 21, 2025, the license holder refused to complete P1’s range of motion exercises, stating two staff were not available to complete them together. The instructions for P1’s range of motion exercises did not instruct the license holder to utilize two staff persons when performing the range of motion exercises with P1. The license holder did not meet P1’s health service needs when the license holder did not complete P1’s range of motion exercises. b. The license holder maintained documentation in P1’s log notes that staff do not assist P1 with picking up P1’s medication from the pharmacy, stating “due to him being independent in medications per his plan of care.” This contradicts what is documented in P1’s support plan addendum. The license holder confirmed that staff “should be assisting P1 with obtaining P1’s medications from the pharmacy in absolute emergent situations.” The license holder did not assist P1 with meeting P1’s health needs when the license holder did not assist P1 with obtaining medications from the pharmacy. Corrective Action Ordered: Within 30 days of receiving this order, you must: · begin providing range of motion exercises to P1 as instructed; · provide a training on P1’s range of motion instructions to all staff that provide direct support to P1; · review and revise P1’s support plan addendum to reflect the steps the license holder will take to support P1 with obtaining medications from the pharmacy when requested; and · submit a copy of these revisions to P1’s support plan addendum to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rule, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P1), the license holder did not incorporate and evaluate positive support strategies as required. P1 support plan addendum stated that P1 experienced bouts of anxiety, outbursts and “demanding” behaviors related to one of their physical health issues. The license holder did not incorporate in writing positive support strategies to an existing treatment, service or other individual plan to support P1 with the anxiety and outbursts they experienced related to the physical health issue. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop positive support strategies for P1 and maintain documentation of these positive support strategies in P1’s support plan addendum; · evaluate, with P1, the established positive support strategies a minimum of every six months to determine whether changes are needed in the positive support strategies used based on the results of the evaluation, and if so, make the appropriate changes; · maintain documentation of these evaluations in P1’s service recipient record; · provide training to all direct support staff who provide direct support services to P1 on P1’s established positive support strategies; · maintain documentation of this training in the personnel records of the staff persons who provide direct support to P1; · submit a copy of the positive support strategies that have been developed for P1 to this licensor; and · submit documentation showing written acknowledgment of training provided to staff on P1’s direct support strategies. On an ongoing basis, you must maintain compliance as required in this subpart. RECOMMENDATION The following recommendations are not requirements of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas. Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license. Area of Minimal Compliance: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (11). P1’s “T-Logs” the term the license holder used for daily log notes, had entries that were written in a subjective manner, reflecting direct support staff’s opinions and personal feelings. It is recommended that the license holder provide retraining to direct support staff who work with P1 on documenting objective and descriptive progress or daily log notes (T-logs) in P1’s service recipient record. 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 64953 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, HCBS Licensor Licensing Division Office of Inspector General 651-431-5757
|
