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Issued: October 1, 2026 Date Reissued: October 20, 2026 Aaron Fisk, Authorized Agent Catholic Charities In Home Program 911 Eighteenth Street North Saint Cloud, Minnesota 56303 License Number: 1070417 Notice: This Amended Correction Order supersedes the original Correction Order dated October 1, 2026, and amends citation 2 in the original Correction Order. The original Correction Order dated October 1, 2026, must be destroyed. AMENDED CORRECTION ORDER Dear Aaron Fisk: On August 19, 2026, and August 20, 2026, a licensing review 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 245D.05, subdivision 4 and Minnesota Statues, section 245D.11, subdivision 2. Violation: For one of six persons whose record was reviewed (P1), the license holder did not review and report medication and treatment issues as required. The license holder was responsible for administration of P1’s medications. The license holder did not ensure that the medication administration record reviews identified medication administration errors and developed and implemented a plan to correct patterns of medication administration errors when identified. The license holder maintained information in P1’s record that documented medication administration record reviews were conducted on May 28, 2026, and July 23, 2026, and no medication errors were identified. This is not consistent with the information in P1’s medication administration records: · P1’s medication administration record for May 2026 documented a medication refusal on May 14, 2026. This medication refusal was not reported to P1’s legal representative and P1’s case manager; and · P1’s medication administration record for June 2026 documented that a medication was out of stock on June 25, 2026. This information was not reported to P1’s legal representative and P1’s case manager. Additionally, the license holder did not ensure coordination of medication refills as required in the license holder’s Safe Medication Assistance and Administration Policy. Corrective Action Ordered: Within 30 days of receiving this, you must: · conduct a medication administration record review for P1 to ensure the information in P1’s medication administration record is current and to identify medication administration errors; · based on the review, you must develop and implement a plan to correct patterns of medication administration errors when identified; · report any situations where a dose of medication was not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person to P1’s legal representative and P1’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.06, subdivision 1, and Minnesota Statutes, section 245D.11, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not complete responsibilities related to incident response and reporting. Minnesota Statues, section 245.91, subdivision 6 defines a potential for closed head injury as “head injuries with loss of consciousness or potential for a closed head injury or concussion without loss of consciousness requiring a medical assessment by a health care professional, whether or not further medical attention was sought.” The license holder maintained an incident report for P2 for a potential for closed head injury that occurred on August 5, 2026. The license holder did not ensure the incident report review included whether P2's support plan addendum or program policies and procedures were implemented as applicable and the determination of whether corrective action is necessary based on the results of the review. Additionally, the license holder did not report the serious injury to the Department of Human Services Licensing Division, and the Office of Ombudsman for Mental Health and Developmental Disabilities as required and conduct an internal review for the incident report of the serious injury. Corrective Action Ordered: Within 30 days of receiving this order, you must; · report the serious injury to Department of Human Services Licensing Division, and the Office of Ombudsman for Mental Health and Developmental Disabilities; and · conduct an internal review of the serious injury for identification of incident patterns, and implementation of corrective action as necessary to reduce occurrences. The review must include: o an evaluation of whether related policies and procedures were followed; o whether the policies and procedures were adequate; o whether there is a need for additional staff training; o whether the reported event is similar to past events with the persons or the services involved; and o whether there is a need for corrective action by the license holder to protect the health and safety of persons receiving services. o 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 staff or the license holder, if any. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (11) and Minnesota Rule 9644.0100, subpart 1. Violation: For one person whose record was reviewed (P4), the license holder did not maintain a service recipient record and did not maintain appropriate data as required. a. The license holder did not maintain progress or daily log notes recorded by the program in P4’s service recipient record. b. The license holder did not maintain appropriate data for P4 that: · revealed the progress or lack of progress towards each outcome or goal for each person; · ensure that staff are accountable for the services provided to the person; and · ensure that services could be evaluated and monitored by the license holder and the commissioner. Corrective Action Ordered: Immediately upon receiving this order, you must begin maintaining progress or daily log notes and the data detailed above in P4’s service recipient record. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 4. Citation: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c). Violation: For two of five staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide orientation training as required. The license holder did not provide orientation training to SP3 and SP4 on the license holder’s drug and alcohol use policy before SP3 and SP4 had direct contact with persons served by the program: · SP3 had direct contact with persons served by the program on March 5, 2026. The license holder provided SP3 training on the license holder’s drug and alcohol use policy on March 20, 2026; and · SP4 had direct contact with persons served by the program on February 4, 2026. The license holder provided SP4 with training on the license holder’s drug and alcohol use policy on February 20, 2026. Corrective Action Ordered: On an ongoing basis, you must ensure that all staff persons are provided with a review of and instruction on your drug and alcohol use policy prior to having any direct contact with persons served by your program, as required in this subdivision. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For four staff persons whose records were reviewed (SP1 through SP3 and SP5), the license holder did not ensure orientation of mandated reporters as required. a. The license holder did not provide SP3 and SP5 with orientation to the license holder’s program abuse prevention plan within 72 hours of first providing direct contact services. b. The license holder did not provide SP1 and SP2 with an annual review of the license holder’s program abuse prevention plan in 2026. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 through SP3 and SP5 with training on your program abuse prevention plan for each CRS location at which the staff person provides direct contact services. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP5), the license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide SP5 with orientation to the individual service recipient needs before having unsupervised direct contact with persons served by the program, sufficient to ensure SP5 achieved and demonstrated an understanding of the person as a unique individual and how to implement their plans, including: · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder; and · the person’s individual abuse prevention plan. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP5 with orientation to individual service recipient needs as detailed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. 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. The license holder did not provide SP1 and SP2 with training on first aid annually in 2026. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with first aid training. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a). Violation: For one staff person whose record was reviewed (SP3), the license holder did not maintain personnel records as required. The license holder did not maintain a personnel record for SP3 that accurately documented the dates of SP3’s training. SP3’s personnel record contained documentation that SP3 received training on multiple dates that SP3 did not work. Corrective Action Ordered: On an ongoing basis, you must maintain accurate personnel records as required in this subdivision for each employee to document and verify staff qualifications, orientation, and training, that includes: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. 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
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