Minnesota

July 1, 2025

Charles Healey, Authorized Agent

Charles Healey Foster Home

306 West 10th Street

Blue Earth, Minnesota 56013

License Number: 1070177 (245D – HCBS)

License Number: 1062361 (AFC)

CORRECTION ORDER

Dear Charles Healey:

On May 19th, 2025, a licensing review of Charles Healey Foster Home, located at 306 West 10th Street, Blue Earth, 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, paragraph (c) and subdivision 2, paragraph (a), clause 4.

Violation: For two of twenty-one persons whose records were reviewed (P1 and P3), the license holder did not provide an orientation to the reporting procedures of alleged or suspected maltreatment of vulnerable adults and the program abuse prevention plan (PAPP) as required.

a. The license holder failed to provide P1 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults and the PAPP within 24 hours of admission.

b. The license holder failed to provide P3 with orientation to the internal and external maltreatment reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. P3’s admission date was in June 2021. The license holder provided P3 with orientation and provided P3’s legal representative with notification of this orientation, in May 2023.

Corrective Action Ordered: Immediately, you must provide orientation to P1 on your internal and external reporting procedures of alleged maltreatment of vulnerable adults and your PAPP.

Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not provide service recipient rights as required.

a. P1’s respite services were initiated on October 21, 2024. The license holder failed to provide a written notice that identified the service recipient rights and an explanation of those rights to P1 and P1’s legal representative within five working days of service initiation. The license holder provided P1’s legal representative with a notice of service recipient rights on November 12, 2024.

b. P3’s services were initiated in June 2021. The license holder failed to provide P3 or P3’s legal representative with a written notice that identified P3’s service recipient rights and an explanation of those rights within five working days of service initiation.

Corrective Action Ordered: Immediately, you must provide all persons and their legal representatives, as applicable, a written notice of the service recipient rights. You must maintain documentation of the person’s or the person’s legal representative’s receipt of the copy and an explanation of the rights according to Minnesota Statutes, section 245D.095, subdivision 3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b).

Violation: For one person whose record was reviewed (P1), the license holder did not ensure the protection of the person’s rights as required.

The license holder failed to ensure the exercise and protection of P1’s right to have use of and free access to common areas in the residence and the freedom to come and go from the residence as well. During a site visit on May 19, 2025, DHS licensors observed a locked door blocked by a rolling cart reportedly used for medications leading to the upstairs level of the P1’s home.

Corrective Action Ordered: Immediately, you must exercise and protect all service recipient rights. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c).

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain documentation in medication administration record as required.

The license holder failed to ensure the following information was documented in P1’s and P2’s medication administration record:

· information on any risks or side effects that were reasonable to expect, and any contraindications to its use;

· the possible consequences if the medication or treatment was not taken or administered as directed; instruction on when and whom to report the following:

o if a dose of medication was not administered or treatment was not performed as prescribed, whether by error by the staff or the person or by refusal by the person; and

o the occurrence of possible adverse reactions to the medication or treatment; and

· notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by staff or the person or by refusal by the person, or of adverse reaction, and when and to whom the report was made.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the documentation detailed above in P1 and P2’s medication administration record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not review medication administration records as required.

The license holder failed to, at a minimum of every three months, review P1 and P2’s medication administration records to identify medication administration errors.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.07, subdivision 1.

Violation: For nineteen persons whose records were reviewed (P3-P21), the license holder did not provide services in compliance with the requirements of the federal waiver plans.

The license holder failed to comply with the federal waiver plans while providing individualized home supports (IHS). The license holder provided IHS to P3-P21 in properties that were owned by SP5 and SP6. The Community-Based Services Manual (CBSM) states that the IHS provider cannot have any direct or indirect financial interest in the property or housing which services are delivered.

Corrective Action Ordered: Immediately, you must comply with the provision of services according to the requirements of this chapter and the federal waiver plans. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

7. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraphs (c) and (d).

Violation: For one person whose record was reviewed (P1), the license holder did not complete service planning as required.

P1’s service initiation was on November 11, 2024. The license holder failed to meet with P1, P1’s legal representative, and P1’s case manager within 45 days of service initiation to determine the following:

· the scope of services to be provided to support the person’s daily needs and activities;

· the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes;

· the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule;

· whether the current service setting is the most integrated setting available and appropriate for the person;

· opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community;

· opportunities for community access, participation and inclusion in preferred community activities;

· opportunities to seek competitive employment and work at competitively paying jobs in the community;

· how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team to ensure continuity of care and coordination of services for the person;

· a discussion of how technology might be used to meet the person’s desired outcomes;

· summarize this conversation and include it in the person’s support plan addendum; and

· include a statement in the summary regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made.

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 requirements listed above and revise P1’s support plan addendum to include the information listed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

8. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraphs (a) and (b).

Violation: For one person whose record was reviewed (P1), the license holder did not document service outcomes and supports as required.

The license holder failed to document in P1’s support plan addendums the following supports and methods to be implemented to support P1 and accomplish outcomes:

· 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.

Corrective Action Ordered: Within 30 days of receiving this order, you must develop and document the information listed above in P1’s support plan addendum. Additionally, you must summarize P1’s status and progress toward achieving the identified outcomes at the time of progress review meetings. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For one person whose record was reviewed (P1), the license holder did not maintain service recipient record as required.

The license holder failed to maintain progress or daily log notes for P1 that were recorded by the program.

Corrective Action Ordered: Immediately, you must begin maintaining progress or daily log notes for P1. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

10. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not inform and provide policies and procedures that affect a person’s rights as required.

a. The license holder failed to inform and provide copies to P1 and P1’s case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure;

· emergency use of manual restraints policy and procedure; and

· data privacy.

P1’s service initiation was November 11, 2024. The license holder provided P1 the grievance policy and procedure on November 12, 2024.

b. The license holder failed to inform P3 and P3’s case manager of the following policies and procedures and failed to provide copies within five working days of service initiation:

· grievance policy and procedure;

· service suspension and termination policy and procedure; and

· emergency use of manual restraints police and procedure.

The license holder informed and provided P3 and P3’s case manager with copies of the license holders policies and procedures that affect P3’s rights in May 2023.

Corrective Action Ordered: Immediately, you must inform and provide copies of the above mentioned policies and procedures to P1 and P1’s case manager. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Rules, chapter 9544.0030, subpart 1.

Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not incorporate and evaluate positive support strategies as required.

The license holder failed to evaluate the identified positive support strategies with P1 and P3, at least every 6 months.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· evaluate with P1 and P3 the identified positive support strategies and document the evaluation in P1 and P3’s service recipient records; and

· based on the results of the evaluation, you must determine whether changes are needed to the positive support strategies used, and, if so, make the appropriate changes.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

12. Citation: Minnesota Rules, part 9544.0080, subpart 1.

Violation: For one person whose record was reviewed (P1), the license holder did not provide notice of the license holder’s policy on the emergency use of manual restraint as required.

The license holder failed to obtain a written acknowledgment from P1 or P1’s legal representative indicating that P1 had been notified of the license holder’s emergency use of manual restraints policy.

Corrective Action Ordered: Immediately, you must obtain a written acknowledgement from P1 or P1’s legal representative has been notified of your emergency use of manual restraint policy and procedure according to Minnesota Rules, part 9544.0080. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart.

13. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For two of four staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide orientation training as required.

a. The license holder failed to provide SP2 orientation training to the following topics within 60 days of hire:

· the job description to provide SP2 orientation training to the following topics:

o responding to and reporting incidents as required under Minnesota Statutes, section 245D.06, subdivision 1; and

o following safety practices established by the license holder and as required in section 245D.06, subdivision 2;

· the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures, including:

o consumer grievance and complaint procedures;

o consumer temporary service suspension and termination policy and procedure;

o prohibition on drug and alcohol use policy; and

o emergency use of manual restraint;

· data privacy requirements according to sections 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 principles of person-centered planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; and

· 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.

b. The license holder failed to provide SP3 with an orientation to the following topics within 60 days of hire:

· current policies and procedures and staff responsibilities related to implementation of the following policies and procedures:

o consumer temporary service suspension,

o consumer service termination,

o use of universal precautions and sanitary practices,

o the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according the requirements in Minnesota Statutes, section 245D.04; and

o sections 245A.65 and 626.557 governing maltreatment reporting and service planning for vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 and SP3 the training detailed above. Additionally, you must document this training in SP3’s personnel record according to Minnesota Statutes, section 245D.095, subdivision 5. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

14. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For three staff persons whose records were reviewed (SP2 and SP4), the license holder did not provide orientation to individual service recipient needs as required.

The license holder failed to provide the following orientation to SP2 and SP4 before having unsupervised direct contact with a person served by the program:

· 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, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans.

Corrective Action Ordered: Within 30 days of receiving of this order, you must provide the orientation listed above to SP2 and SP4 for each service recipient that the staff person provides direct support services to. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

15. Citation: Minnesota Statutes, section 245D.65, subdivision 3.

Violation: For one of four staff persons whose record was reviewed (SP4), the license holder did not provide orientation to a mandated reporter as required.

SP4’s hire date was April 1, 2025. The license holder failed to provide orientation to vulnerable adult maltreatment reporting within 72 hours of first providing direct contact. The license holder provided the required orientation on May 13, 2025.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.

16. Citation: Minnesota Statutes, section 245D.09, subdivision 5.

Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training as required.

a. The license holder failed to provide SP2 with annual training in 2025 on the following topics identified in subdivision 4, as required:

· data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), 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, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 265A.65, subdivision 3;

· 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;

· 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.

b. The license holder failed to provide SP3 with annual training in 2024 on the following topics identified in subdivision 4, as required:

· 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;

· 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;

· 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 SP3 the training detailed above. Additionally, you must document this training in SP2 and SP3’s personnel record according to Minnesota Statutes, section 245D.095, subdivision 5. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

17. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For one staff person whose record was reviewed (SP3), the license holder did not maintain a personnel record as required.

The license holder failed to maintain the following documentation in SP3’s personnel record as required:

· SP3’s date of hire and completed application; and

· documentation of staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the instructor.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain SP3’s date of hire and application in SP3’s personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision.

18. Citation: Minnesota Statutes, section 245D.10, subdivision 2.

Violation: The license holder did not establish and maintain policies and procedures related to grievances as required.

The license holder failed to establish and maintain a grievance policy that included the address of the highest level of authority in the program as required.

Corrective Action Ordered: Immediately, you must:

· update your grievance policy to include the address of the highest level of authority in the program;

· provide all persons, their legal representatives, as applicable, and their case managers with this update; and

· maintain documentation of the person’s or their legal representative’s and case manager’s receipt of the copy of your grievance policy.

Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

19. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3.

Violation: The license holder did not ensure the designated coordinator and the designated manager (SP1) provided program management and oversight of the services provided by the license holder as required.

a. The license holder designated SP1 as the designated coordinator. See citations 1 through 18 regarding the license holder’s failure to ensure SP1 met the following responsibilities:

· 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 designated SP1 as the designated manager. See citations 1 through 18 regarding the license holder’s failure to ensure SP1 met the following responsibilities:

· 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.

Corrective Action Ordered: Within 30 days of receiving this order, you must submit documentation to your licensor that the designated coordinator has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 2 and the designated manager has acknowledged their responsibilities as required in Minnesota Statutes, section 245D.081, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision.

Submissions required as part of a corrective action ordered must be sent to your Licensor at:

1. By secure email at Dylan.Sobota@state.mn.us; or

2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below:

Commissioner, Department of Human Services

ATTN: Dylan Sobota

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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.

Dylan Sobota, HCBS Licensor

Licensing Division

Office of Inspector General

651-431-2690

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/