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August 22, 2022 Mai Vang, Authorized Agent Harmony Adult Day Center LLC 1119 Hawthorne Avenue East Saint Paul, Minnesota 55106 License Number: 1104184 (Rule 223) CORRECTION ORDER Dear Mai Vang: On August 16, 2022, a licensing review of Harmony Adult Day Center LLC, located at 475 Etna Street, Saint Paul, Minnesota, was conducted to determine compliance with Minnesota Statutes and Rules governing adult day care services under Minnesota Rules, parts 9555.9600 through 9555.9730 (Rule 223). 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). Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse and prevention plan (PAPP) as required. a. The license holder failed to provide orientation to P1 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. b. The license holder failed to provide orientation to P2 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. P2’s admission date was November 25, 2021. The license holder maintained documentation that P2 was provided orientation on the license holder’s internal and external reporting procedures and PAPP on December 1, 2021. Corrective Action Ordered: Immediately, you must provide P1 orientation to your internal and external reporting procedures and PAPP. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records for orientation on your internal and external reporting procedures and PAPP; and · for participants that have not received the required orientation, you must develop a plan detailing how the orientation will be provided within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P1 as part of the initial individual program plan or service plan. There was no IAPP in P1’s record. b. The license holder failed to review P2’s IAPP quarterly as part of the review of the program plan or service plan. The license holder maintained documentation that P2’s IAPP was most recently reviewed on April 12, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1; · review P2’s IAPPs with P2’s interdisciplinary teams and document the review; · complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and · for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P1), the license holder did not distribute policy and program information to participants as required. The license holder failed to distribute the following policies and program information to P1 upon admission: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. Corrective Action Ordered: Immediately, you must distribute the policies and program information detailed above to P1. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records that evaluates if your policies and program information were provided to each participant; and · for participants who did not receive your policies and program information, you must develop a plan detailing how your program will distribute the policies and program information to the participant and their caregiver within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9555.9660. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not develop and maintain a written record as required. a. The license holder failed to maintain a record for P1, including: · an application form signed by P1 or P1’s caregiver that included: o P1’s name, address, date of birth, sex, date of admission, living arrangement, telephone number, and source of referral; o the name and telephone number of the person to call in case of emergency involving P1 and name and number of another person to call if that person cannot be reached; and o the name and telephone number of P1’s physician or medical provider; · a medical report, dated within the three months prior to or 30 calendar days after P1’s admission to the center, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that included: o a report on physical examination; and o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and · participation reports and progress notes that were recorded at least monthly. a. The license holder failed to maintain a medical report in P2’s record, dated within the three months prior to or 30 calendar days after P2’s admission to the center, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that included: · a report on physical examination; and · a release signed by the physician indicating whether P2 may engage in a structured exercise program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain all required information detailed above in P1 and P2’s participant records; · complete an audit of all participants’ records to ensure requirements in Minnesota Rules, part 9555.9660 are maintained; and · for participants who do not have a complete participant record as required, you must develop a plan detailing how your program will maintain all required documentation within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part. 5. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not complete initial service planning as required. a. The license holder failed to conduct a needs assessment for P1 that included: · P1’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · §P1’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · §P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received from the P1’s physician. b. The license holder failed to develop a preliminary service plan for P1 that included the following information and specifications: · scheduled days of P1's attendance at the center; · transportation arrangements for getting P1 to and from the center; · P1's nutritional needs and, where applicable, dietary restrictions; · role of P1’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P1 would take part immediately upon admission. c. The license holder failed to conduct a needs assessment for P2 that addressed the person’s physical status, determined from P2’s medical report. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct a needs assessment for P1; · develop a preliminary service plan for P1 that includes the information and specifications detailed above; · complete an audit of all participants’ needs assessments and preliminary service plans to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 2 are maintained; and · for participants who do not have needs assessments and preliminary service plans that include all requirements, you must develop a plan detailing how your program will maintain a complete needs assessment within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not develop a written plan of care as required. a. The license holder failed to develop a written plan of care for P1 that included: · §an update of the preliminary service plan and additional services required by P1; · short and long-term objectives for P1 stated in concrete, measurable, and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · provisions for quarterly review and quarterly revision of the individual plan of care. b. The license holder failed to develop a written plan of care for P2 that included: · short and long term objectives for P2 stated in concrete, measurable, and time specific outcomes; and · provisions for quarterly review and quality revisions of the individual plan of care. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1 and P2, with the person, that include the information listed above; · complete an audit of all participants’ written plans of care to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained; and · for participants who do not have a written plan of care that includes all required information, you must develop a plan detailing how your program will maintain a complete written plan of care within 60 days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, 4, 6, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to ensure menus for all meals and snacks were approved by a registered dietitian and met all applicable state rules and laws and United States Department of Agriculture regulations. b. The license holder failed to maintain a record indicating the menu for all meals served for at least six months. c. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly prior to May 2022. d. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2021 and 2022. e. The license holder failed to have a monthly plan for diversified daily program activities that included: · socialization activities, such as group projects and recreational activities; · cultivation of personal interests, such as arts, crafts, and music; and · activities designed to increase the participant's knowledge and awareness of the environment and to enhance language and conceptual skills. f. The license holder failed to maintain a family and social history for P1. § Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure your menus for all meals and snacks have been approved by a registered dietician; · have your exercise program reviewed by a registered physical therapist; · develop a monthly plan for diversified daily program activities; and · maintain a family and social history for P1. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For three of three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain the following in SP1 and SP2’s personnel records: · a job description; · an employment application or resume indicating that the employee met the requirements in part 9555.9680, subpart 2; and · documentation of an annual performance evaluation. b. The license holder failed to maintain the following in SP3’s personnel record: · a job description; and · documentation of an annual performance evaluation. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the documentation detailed above in SP1, SP2, and SP3’s personnel records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP1, SP2, and SP3 orientation to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact. Corrective Action Ordered: Immediately, you must provide the required orientation detailed above to SP1, SP2, and SP3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1, SP2, and SP3 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least four hours of supervised orientation before the employee worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1, SP2, and SP3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d). Violation: The license holder did not post a copy of the internal and external reporting policies and procedures, including the telephone number of the common entry point as defined in section 626.5572, subdivision 5, in a prominent location in the program as required. Corrective Action Ordered: Immediately, you must post copy of the internal and external reporting policies and procedures in a prominent location in the program. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rules, part 9555.9720, subparts 8 and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure rugs had nonskid backing. b. The license holder failed to rehearse the fire escape plan at least four times in 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure rugs have nonskid backing; and · rehearse your fire escape plan and record the date of the rehearsal in the file of emergency plans. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 13. Citation: Minnesota Rules, part 9555.9730, subparts 3 and 5. Violation: The license holder did meet physical plant and space requirements. a. The license holder failed to equip restrooms used by participants with a mechanism that participants could use to signal staff members by light or by sound if participants needed assistance. b. The license holder failed to have a room or an area that could be used as private space for providing personal hygiene services or social services to participants. Corrective Action Ordered: Immediately, you must: · equip restrooms used by participants with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance.; and · have a room or an area that can be used as private space for providing personal hygiene services or social services to participants. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 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. A. 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 64242 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, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General
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