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April 24, 2026 CERTIFIED MAIL Michelle Schaefer, Authorized Agent Beacon Specialized Living Minnesota Inc 1355 Mendota Heights Road Suite 260 Mendota Heights, Minnesota, 55120 License Number: 1070450 (245D- HCBS) 1124940 (Community Residential Setting-HCBS) ORDER OF CONDITIONAL LICENSE Dear Michelle Schaefer: The Department of Human Services (DHS) is placing your license to provide Home and Community-Based Services at Beacon Specialized Living Minnesota Inc, 1355 Mendota Heights Road, Mendota Heights, Minnesota, on conditional status for two years, beginning April 24, 2026. This means you must meet certain conditions to maintain your license, detailed below. This order applies to all services licensed under Chapter 245D and the service sites detailed in the Applicability of the Conditional License section below. This order is based on your noncompliance with Home and Community-Based Services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On October 14, 2025, and October 15, 2025, DHS licensors conducted a licensing review at your facility located at 1355 Mendota Heights Road, Mendota Heights, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program did not to comply with the laws and rules that apply to licensed Home and Community-Based Services, citing 24 violations. Licensing Violations Determined on October 14 and October 15, 2025 DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violation 1. Violation: The license holder did not ensure the designated coordinators, and the designated managers provided program management and oversight of the services provided by the license holder as required. a. The license holder did not ensure designated coordinators met the following responsibilities as evidenced by citations 2 through 21: · provide oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · take the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · provide instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluate the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes have been achieved according to the requirements in section 245D.07. b. The license holder did not ensure the designated managers met the following responsibilities as evidenced by citations 22 through 24: · maintain current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; · ensuring corrective action was taken when ordered by the commissioner; and · evaluate the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Service Recipient Violations 2. Violation: For one of ten persons whose record was reviewed (P4), the license holder did not provide orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment as required. The license holder did not provide P4 or P4’s legal representative with orientation to the license holder’s internal and external reporting procedures related to alleged or suspected maltreatment within 24 hours of admission. The license holder initiated services for P4 on February 27, 2025, and orientation was provided to P4’s legal representative on March 11, 2025. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1 Repeat Violation: In a Correction Order that DHS issued on June 24, 2025, April 7, 2025, and September 26, 2025, you were previously found in violation of the same statute. 3. Violation: For two persons whose records were reviewed (P4 and P8), the license holder did not establish and enforce abuse prevention plans as required. a. The license holder did not provide P4’s legal representative with orientation to the program abuse prevention plan (PAPP) within 24 hours of admission. The license holder initiated services for P4 on February 27, 2025, and orientation was provided to P4’s legal representative on March 11, 2025. b. The license holder did not include a statement of measures in the individual abuse prevention plans for P4 and P8 that will be taken to minimize the risk of abuse to the vulnerable adult when the individual assessment required in section 626.557, subdivision 14, paragraph (b), indicated the need for measures in addition to the specific measures identified in the program abuse prevention plan.
Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 4. Violation: For three persons whose records were reviewed (P2, P4, and P8), the license holder did not provide service recipient rights 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 P4 or P4’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. The license holder initiated services for P4 on February 27, 2025 and provided P4 and P4’s legal representative with a written notice on March 11, 2025. b. The license holder did not provide P2 or P2’s legal representative and P8 or P8’s legal representative with a written notice that identified the service recipient rights in subdivision 2 and 3 and an explanation of those rights annually in 2023 and 2024 for P2 and 2022, 2023, 2024 for P8. In a correction ordered dated April 7, 2025, the license holder was ordered to provide P2 or P2’s legal representative and P8 or P8’s legal representative with a written notice that identified the service recipient rights in subdivisions 2 and 3 and an explanation of those rights annually. At the time of the licensing review on October 15, 2025, the license holder had not implemented the corrective action ordered. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 5. Violation: For two persons whose records were reviewed (P4 and P8), the license holder did not ensure the exercise and protection of the person’s rights as required. a. The license holder did not ensure and exercise P4’s right to have free access to common areas in the residence. On October 15, 2025, a DHS licensor observed the laundry room was locked and was not freely accessible to persons served at Community Residential Settings (CRS) license 1127370. Additionally, P4’s clothing was locked in the laundry room preventing P4 access to their clothing. b. The license holder did not ensure the exercise and protection of P8’s right to personal privacy when P8’s support plan addendum dated September 5, 2025, documented that P8’s phone use must be supervised. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, June 18, 2025, and March 2, 2026 you were previously found in violation of the same statute. 6. Violation: For one person whose record was reviewed (P4), the license holder did not assist with safekeeping of funds as required. The license holder was assigned responsibility to assist P4 with safekeeping of funds. The license holder did not document the preferences of P4’s legal representative or P4’s case manager for receiving a statement that itemizes receipts and disbursements of funds. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on June 24, 2025, you were previously found in violation of the same statute. 7. Violation: For one person whose record was reviewed (P4), the license holder did not provide services in response to the person’s identified needs as specified in the support plan and support plan addendum as required. The license holder did not ensure the support plan addendum accurately documented P8’s elopement protocol. P8’s support plan addendum contained a log note dated October 10, 2025, which a staff person documented that they asked the program director “…which version of [P8]’s elopement protocol was currently being used. The program director indicated that they believed staff were still referencing an older version.” Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. Repeat Violation: In a Correction Order that DHS issued on April 18, 2023, April 7, 2025, June 24, 2025, September 26, 2025, December 9, 2025, and January 28, 2026, you were previously found in violation of the same statute. 8. Violation: For one person whose record was reviewed (P4), the license holder did not provide written reports as required. The license holder was assigned to provide P4’s expanded support team with quarterly progress review reports. The license holder initiated services to P4 on February 27, 2025, and first provided a progress review report on August 7, 2025. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 9. Violation: For one person whose record was reviewed (P4), the license holder did not complete initial service planning and review for intensive services as required. The license holder did not conduct an initial service planning meeting before providing 45 days of service to P4. P4’s service initiation was on February 27, 2025, and the initial service planning meeting was held on April 21, 2025. Additionally, the license holder did not have a discussion of how technology might be used to meet P4’s desired outcomes at P4’s initial service planning meeting. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on April 18, 2023, and April 7, 2025, you were previously found in violation of the same statute. 10. Violation: For six persons whose records were reviewed (P3, P4, P5, P6, P7, and P8), the license holder did not develop a service plan that documented the service outcomes and supports as required. a. The license holder did not document the following information in P3, P5, P6, P7, and P8’s support plan addendums: · 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. In a correction ordered dated April 7, 2025, the license holder was ordered to document the above-mentioned information for P3, P5, P7, and P8 in their support plan addendum. At the time of the licensing review on October 14, 2025, and October 15, 2025, the license holder had not complied with the corrective action ordered. b. The license holder did not document the methods or actions that would be used to support P4 to accomplish the service outcomes to make any changes or modifications to the physical and social environments necessary when the service supports are provided. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4.
11. Violation: For one person whose record was reviewed (P8), the license holder did not complete service plan review and evaluation as required. The license holder did not provide P8, P8’s legal representative, and P8’s case manager with a report in 2024 that summarized P8’s status and progress toward achieving the identified outcomes, made recommendations, and identified the rationale for changing, continuing, or discontinuing implementation of the supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 12. Violation: For two persons whose records were reviewed (P3, and P4), the license holder did not provide copies of policies and procedures as required. a. The license holder did not provide P3’s case manager with a copy of the policies and procedures affecting a person’s rights under section 245D.04 within five working days of service initiation. In a correction ordered dated April 7, 2025, the license holder was ordered to provide P3’s case manager with a copy of their policies and procedures affecting a person’s rights. At the time of the licensing review on April 7, 2025, the license holder did not comply with the corrective action ordered. b. The license holder-initiated services for P4 on February 27, 2025. The license holder did not provide P4’s legal representative and P4’s case manager of the policies and procedures affecting a person’s rights under 245D.04 within five working days of service initiation. The policies and procedures were provided to P4’s legal representative on March 11, 2025, and P4’s case manager on March 10, 2025. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 13. Violation: For four persons whose records were reviewed (P3, P5, P6, and P7), the license holder did not evaluate positive support strategies with the person as required. The license holder did not evaluate with P3, P5, P6, and P7, at least every six months, whether the identified positive support strategies meet the standards in subpart 2. In a correction ordered dated April 7, 2025, the license holder was ordered to evaluate with P3, P5, and P7 whether the identified positive support strategies met standards. At the time of the licensing review on October 14, 2025, and October 15, 2025, the license holder had not complied with the corrective action ordered. Statute Violated: Minnesota Rules, part 9544.0030, subpart 1. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. 14. Violation: For one person whose record was reviewed (P6), the license holder did not restrict the use of prohibited procedures. Minnesota Rules 9544.0060, subpart 2 lists specific prohibited actions or procedures including the use of token reinforcement programs or level programs that include a response cost of negative punishment component. The license holder implemented a behavior program that required P6 to complete one chore and one hygiene task to earn the ability to spend money or take part in activities. The license holder implemented a prohibited procedure when the program included a response cost or negative punishment component that didn’t allow P6 to take part in activities that had been planned if P6 did not complete the tasks. Statute Violated: Minnesota Rules, part 9544.0060, subpart 2, section Q. Health Service Needs Violations 15. Violation: For five persons whose records were reviewed (P1, P4, P6, P7, and P8), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for medication administration for P1. The license holder documented multiple medication errors between June 2025 and August 2025, where P1 did not receive multiple daily prescribed medications due to the program not having the medication available. The license holder did not implement medication administration procedures to ensure P1 took medications and treatments as prescribed when the license holder did not complete medication refill requests were communicated in a timely manner. b. The license holder did not obtain written authorization from P4’s legal representative to administer medication or treatment prior to administering medications. The license holder began administering medications on February 27, 2025, and obtained written authorization on March 5, 2025. c. The license holder was assigned responsibility for medication administration for P7. The license holder maintained documentation of one of P7’s medications not being administered on August 18, 2025, due to the program not having the medication available. The license holder did not implement medication administration procedures to ensure P7 took medications and treatments as prescribed when the license holder did not ensure medication refill requests were communicated in a timely manner. d. The license holder was assigned responsibility for medication administration for P8. The license holder documented multiple medication errors between June 2025 and October 2025, where P8 did not receive daily prescribed medications on at least 15 occasions, due to the program not having the medication available. The license holder did not implement medication administration procedures to ensure P8 took medications and treatments as prescribed when the license holder did not ensure medication refill requests were communicated in a timely manner. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2. Repeat Violation: In a Correction Order that DHS issued on September 19, 2025, you were previously found in violation of the same statute. 17. Violation: For four persons whose records were reviewed (P1, P6, P7, and P8), the license holder did not review and report medication and treatment issues as required. a. The license holder did not review P1’s medication administration record (MAR) at least every three months to ensure that the information maintained in P1’s MAR was current and to identify medication administration errors. b. The license holder did not ensure that medication administration issues for P6 were reviewed as required. The license holder maintained documentation of a review of P6’s MAR dated September 1, 2025, that was inaccurate. The MAR review indicated there were no medication administration errors or refusals; however, DHS licensors identified multiple missed medications on P6's MAR on August 18, 2025, and refused medications on August 25, 2025. c. The license holder did not ensure that medication issues for P7 were reviewed as required. The license holder maintained documentation of a review of P7’s MAR dated September 4, 2025, that was inaccurate. The MAR review indicated no medication administration errors for P7; however, DHS identified documentation in P7’s record of a missed medication on August 18, 2025. d. The license holder documented at least three medication administration errors between June 2025, and October 2025, when P8 did not receive daily prescribed medication due to the medications not being refilled by the license holder in a timely manner or P8’s refusal to receive medications. The license holder did not report medication errors to P8’s legal representative or case manager as they occurred. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, September 19, 2025, and January 12, 2026 you were previously found in violation of the same statute. 18. Violation: For five persons whose records were reviewed (P4, P5, P6, P7, and P8), the license holder did not develop, implement and maintain documentation regarding psychotropic medications as required. Target symptoms refer to any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. a. The license holder was assigned responsibility of medication administration for P4, P5, P6, P7, and P8, including psychotropic medications. The license holder did not maintain documentation of a description of the target symptoms for each psychotropic medication prescribed to P4, P5, P6, P7, and P8 in the person’s support plan addendum. In a correction ordered dated April 7, 2025, the license holder was ordered to ensure P5’s support plan addendum contained a description of the target symptoms that the psychotropic medication is to alleviate. At the time of the licensing review on October 14, 2025, and October 15, 2025, the license holder did not comply with the corrective action ordered. b. The license holder was assigned to provide P4’s expanded support team with a review of symptom-related monitoring data every three months. The license holder initiated services to P4 on February 27, 2025, and first provided a review of the monitoring data on August 5, 2025. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on July 1, 2026, and April 7, 2025, you were previously found in violation of the same statute. 19. Violation: For two persons whose records were reviewed (P6 and P7), the license holder did not report and review incidents as required. a. The license holder did not report an incident that occurred on July 12, 2025, to P6’s legal representative and case manager within 24 hours of an incident occurring while services were being provided. The license holder reported the incident to P6’s legal representative and case manager on July 14, 2025. Additionally, the license holder did not conduct a review of the incident report for identification of incident patterns, and implementation of corrective action as necessary to reduce occurrences. b. P7 was involved in an incident on September 15, 2025, that required physician treatment. The license holder did not conduct a review of the incident report for identification of incident patterns, and implementation of corrective action as necessary to reduce occurrences. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 1. Repeat Violation: In a Correction Order that DHS issued on April 18, 2023, April 7, 2025, January 28, 2026, March 2, 2026, and April 9, 2026, you were previously found in violation of the same statute. 20. Violation: For one person whose record was reviewed (P4), the license holder used a prohibited procedure as a behavioral or therapeutic program to reduce or eliminate behavior. Minnesota Statutes, section 245A.02, subdivision 3b defines “chemical restraint” to mean the administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s medical of psychological condition. The license holder was responsible for medication administration for P4. The license holder documented a pro re nata (PRN) protocol for P4 that stated that staff would administer his/her PRN medication for target symptoms listed as physical aggression or property destruction after attempting at least five alternative calming methods. P4’s PRN medication was administered on August 19, 2025, when P4 was not displaying target symptoms, which indicated that P4’s medication was administered as a chemical restraint. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 5. 21. Violation: For two persons whose records were reviewed (P1 and P8), the license holder did not enforce and maintain policies and procedures for safe medication administration as required. The license holder was responsible for medication administration for P1 and P8. The license holder did not enforce the program’s safe medication administration policy when the license holder did not administer medications within 60 minutes before or after the prescribed time for multiple medications for P1 and P8. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 2. Staffing Standards Violations 22. Violation: For two of fourteen staff persons whose records were reviewed (SP3 and SP7), the license holder did not provide orientation training within 72 hours of first providing direct contact services and an annual review of the license holder's program abuse prevention plan (PAPP) as required. Minnesota Statutes, 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent year. a. The license holder did not provide SP3 orientation to the license holder’s PAPP within 72 hours of first providing direct contact services. b. The license holder did not provide SP7 with annual training to the license holder’s program abuse prevention plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. 23. Violation: For one staff person whose record was reviewed (SP7), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not review and provide SP7 with instruction on P8’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, P8’s IAPP, and P8’s elopement protocol, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a.
24. Violation: For one staff person whose record was reviewed (SP7), the license holder did not provide annual training as required. The license holder did not provide SP7 with annual training in the following areas in 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; · 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 in; 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. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on April 7, 2025, you were previously found in violation of the same statute. Nature, chronicity, or severity of violations and effect of violation(s) on health, safety, or rights of persons served by the program The Commissioner has considered the nature, chronicity, and severity of the violation(s) of law or rule and the effect of the violation on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a conditional license is appropriate. · Nature: The license holder was issued a correction order on April 7, 2025, that cited 22 violations. Despite the corrective action that was ordered in that correction order, the license holder continued to demonstrate noncompliance and did not provide program coordination, evaluation, and oversight of services at the time of the licensing review on October 14, 2025, and October 15, 2025. · Chronicity: Your program received its license on January 1, 2014. DHS provided you direction and resources regarding these rules and laws, including the importance of compliance. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o April 24, 2026: Conditional License (this order): 24 violations (19 repeat) o December 18, 2025: Order Lifting Temporary Immediate Suspension o July 10, 2025: Temporary Immediate Suspension: Imminent risk of harm to persons served o April 9, 2026: Correction Order: 1 violation (1 repeat) o March 2, 2026: Correction Order: 2 violations (2 repeat) o January 28, 2026: Correction Order: 2 violations (2 repeat) o January 12, 2026: Correction Order: 1 violation (1 repeat) o December 9, 2025: Correction Order: 1 violation (1 repeat) o September 26, 2025: Correction Order: 2 violations (2 repeat) o September 19, 2025: Correction Order: 2 violations (1 repeat) o June 24, 2025: Correction Order: 4 violations (2 repeat) o June 18, 2025: Correction Order: 4 violations (2 repeat) o April 7, 2025: Correction Order: 22 violations (7 repeat) o April 1, 2025: Correction Order: 1 violation o December 6, 2024: Correction Order: 3 violations (2 repeat) o August 29, 2024: Order to Pay a Fine – 3 violations, $1,000 maltreatment fine o January 24, 2024: Correction Order: 2 violations o April 18, 2023: Correction Order: 3 violations (3 repeat) o June 17, 2022: Correction Order: 1 violation · Severity: The designated coordinators and designated managers did not provide the coordination of service delivery and evaluation of program management and oversight which is required to ensure your program remains in compliance with licensing requirements. License holders are required to hire qualified and competent individuals for these roles to ensure licensing compliance is maintained. As a result of not hiring a qualified and competent designated coordinators and designated managers, you were found in violation of the 24 citations described in this order. The license holder did not meet the responsibilities related to individual abuse prevention plans when a statement of measures to minimize the risk of abuse was not included in the plan. This could negatively impact the health and safety of persons served, as their identified vulnerabilities change, the review of the individual abuse prevention plan provides staff with knowledge of potential risks and the proactive strategies the staff will utilize to reduce these risks. Information maintained in a person served record included documentation of prohibited procedures being utilized, including chemical restraints. A medication was administered not in accordance with the person served PRN administration plan. The use of the medication without strict adherence to the plan raises concerns about why less restrictive, person-centered interventions weren’t attempted or considered. You did not develop service outcomes and supports based on assessments of the person’s needs. Because the person’s level of need required intensive support services, you were required to support the person in acquiring, retaining, or improving skills. You did not document how you would address the person’s needs which included measurable and observable criteria for identifying when the desired outcome has been achieved. You did not show you provided any services beyond basic support services when you were legally required and paid to provide intensive support services. Many of the violations involve your inability to properly administer medications, which could affect the health and safety of the service recipients. You are not implementing the program’s safe medication policy when medications are being administered outside of the prescribed medication window. You did not ensure that each person has the medications available for administration. You are not ensuring that service recipients receive the necessary health services and medication that could result in significant health implications by those who are dependent on the competent assistance of the license holder. These violations relate to the health and well-being of the person served and put their health at risk. You did not report incidents that occurred within 24 hours of the incidents occurring as required. When incidents are not reported promptly, there is a greater chance that important details may be lost, risks may go unmitigated, and similar incidents could occur again. Internal reviews were not completed to determine if program practices were not followed to identify incident patterns and implementation of corrective action as necessary to reduce occurrences. Over time, this can lead to increased safety risks, diminished quality of care or services, potential legal or regulatory consequences, and a loss of trust from persons served and their team members. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Home and Community-Based Services (1070450) and your license to provide community residential settings (specific to 1124940) are placed on a conditional status. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the program’s operation, well-being of persons served by your program, available evaluations of the program by persons receiving services; the qualifications of staff persons; the ability to demonstrate competent knowledge of applicable laws and rules; and the results of background studies. DHS is concerned about your program’s operation because since you were licensed in 2014, DHS has issued 16 correction orders, and 24 licensing violations determined during the most recent licensing review. The number of violations demonstrates that you did not adequately oversee your responsibilities as a license holder, to ensure compliance, and take corrective action when ordered by the Commissioner. DHS’ concerns about your program’s operation and ability to demonstrate competent knowledge were also demonstrated in your inability to comply with service planning and health needs requirements. These requirements protect the health and safety of persons served and are minimum standards for license holders. Inability to comply with these requirements impedes the Commissioner’s ability to ensure the level of care that is required by persons served is being provided as mandated by law. Service planning and health needs requirements are essential to keeping vulnerable adults and children safe and ensuring persons served are receiving necessary services. Your lack of service planning, implementation and documentation of health needs posed a risk that staff would not know about the unique needs of the vulnerable people served. Additionally, your allowance of the use of prohibited procedures in your program presents concerns about your program’s operation, and well-being of person served. The use of prohibited procedures poses a physical and emotional risk to persons served, results in loss of autonomy, and is in violation of the individual’s rights. Based on the Commissioner’s evaluation of the program, a conditional license is warranted. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Home and Community-Based Services (1070450) and your license to provide community residential settings (specific to 1124940) are on a conditional license. Corrective action required Within 60 days, you must correct the violations cited above. Compliance with this order will be reviewed onsite on an ongoing basis. If you do not demonstrate substantial compliance with Home and Community-Based Services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Applicability of Conditional License This Order of Conditional License applies to all of your service sites operated under this 245D license because the 24 violations (20 repeat violations) show you lack competent knowledge of the laws required to operate an HCBS program. Since the violations involved your lack of competence to hire and train competent designated coordinators and designated managers; they involved staff who could provide services at any service site; persons served at multiple service sites; and they were serious in nature, this conditional order applies to all your 245D service sites. Service site is defined in 245D.02, subdivision 32. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (a). In addition, based on the recommendation of Scott County Health and Human Services, this conditional license also applies to the Community Residential Services (CRS) Beacon Specialized Living Minnesota Inc – Louisville site, license number 1124940, located at 2150 133rd Street West, Shakopee, MN 55379 because they are not operating in compliance with applicable laws and rules. Legal Authority: Minnesota Statutes, section 245A.06, subdivision 1a, paragraph (b). CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services and Community Residential Services licensing rules and statutes, you are required to comply with the following terms: 1. Immediately, you must discontinue the use of prohibited procedures and provide training to all employees that provide direct care on staff responsibilities related to prohibited procedures. 2. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your licenses, the reasons your licenses were made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the licenses are on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the licenses are on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the licenses, the reasons the licenses were made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 3. Within 30 days of receiving this order, you must: e. review with all designated coordinators and designated managers the requirements in Minnesota Statutes 245D.081, subdivision 2 and 3; f. establish a plan of how designated coordinators and designated managers will fulfill each of the duties in 245D.081; g. submit documentation of the review of the requirements and the established plan as stated above; and h. maintain documentation in accordance with Minnesota Statutes 245D.095. 4. Within 60 days of receiving this order, you must: a. establish a written plan detailing how you will ensure the corrective action ordered in this order is completed; b. detail the roles and responsibilities that your designated coordinator and designated manager will have in completing corrective action; and c. include the names of the designated coordinator and designated manager for each location, along with a clear description of their specific responsibilities at each service location. 5. Within three months of receiving this order, you must review your medication administration procedures with all direct support staff and maintain documentation in accordance with Minnesota Statutes 245D.095. 6. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 7. You will not be granted any DHS or county variances for the duration of the conditional license. 8. During the first six months of your conditional license, you must notify your DHS licensor prior to admitting new persons served to your program. The notification to your licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service, if a person served is receiving residential services the location must be submitted, and documentation of compliance with term 2 of your conditional license. In addition to the conditions noted above, Scott County has added the following condition specific to your CRS Beacon Specialized Living Minnesota Inc - Louisville site, license number 1124940, located at 2150 133rd Street West, Shakopee, MN 55379: 9. Throughout the entirety of the conditional license, you must notify your Scott County licensor and receive approval prior to admitting new persons served to your program. The notification to your county licensor must include the name of the person served, the name and contact information for the person’s case manager, the service(s) you will provide to the person, the person’s anticipated service initiation date for each service. After approval is received from your licensor and service initiation of a new person has occurred, you must submit the following to your Scott County licensor before providing 45 days of service or within 60 calendar days of service initiation, whichever is shorter: · person served support plan addendum; and · staff training related to the individual service recipient needs. 10. You may not increase the capacity of the home for the duration of the conditional license. 11. You must submit monthly incident reports to the Scott County Licensor and assigned case managers, including outcomes of any internal reviews. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at jolene.reinke@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can fax 651-431-7673 or mail using the information below: Commissioner, Department of Human Services ATTN: Jolene Reinke Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Submissions required to your county licensor as part of this conditional order must be sent to your Scott County licensor at: 1. By secure email at mrabine@co.scott.mn.us; or 2. If you are unable to make submissions to your county licensor securely through email, you can mail using the information below: Scott County Health and Human Services/Licensing ATTN: Molly Rabine 200 Fourth Avenue West Shakopee, MN 55379-1220 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Home and Community-Based Services laws and rules. Posting of this licensing action You are required to place this Order of Conditional License in a place that is clearly noticeable to the people receiving services and all visitors to the facility for two years, even if you appeal. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community-Based Services are required to follow Minnesota Statutes 245A, 245C and 245d, and Minnesota rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · The requirement to post this order in a clearly visible location is required under Minnesota Statutes, section 245A.06, subdivision 8. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Leota Bemis, Supervisor, at 651-431-5637. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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