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August 23, 2022 Mathew Bedard, Authorized Agent Buffalo Adult Day Center 200 Park Lane Buffalo, Minnesota 55313 License Number: 800262 (Rule 223) CORRECTION ORDER Dear Mathew Bedard: On August 22, 2022, a licensing review of Buffalo Adult Day Center, located at 619 Montrose Boulevard, Buffalo, 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 2, paragraph (b). Violation: For three of three participants whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop IAPPs for P1, P2, and P3 that included a statement of measures that would be taken to minimize the risk of abuse to the person and other vulnerable adults when the IAPP indicated susceptibility to abuse. b. The license holder failed to review P2 and P3’s IAPPs 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 September 9, 2021. · The license holder maintained documentation that P3’s IAPP was most recently reviewed on October 20, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop IAPPs for P1, P2, and P3 that include a statement of measures that will be taken to minimize the risk of abuse to the person and other vulnerable adults when the individual assessment indicates the need for measures; · review P1, P2, and P3’s IAPPs with the person’s interdisciplinary team 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not include information in the participant’s written record as required. a. The license holder failed to maintain a medical report in P1’s record that included: · indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; and · documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants. b. The license holder failed to include the following information in P2’s record: · an application form that included the telephone number of P2’s physician or medical provider; and · a medical report dated within the three months prior to or 30 days after P2’s admission to the center. P2 was admitted to the center on March 16, 2021 and the license holder maintained a medical report for P2 on June 17, 2021. c. The license holder failed to include the following information in P3’s record: · an application form that included the telephone number of P3’s physician or medical provider; · a medical report dated within the three months prior to or 30 days after P3’s admission to the center. P3 was admitted to the center on April 26, 2021 and the license holder maintained a medical report for P3 on July 21, 2021 Additionally, the license holder failed to maintain a report on a physical examination, updated annually in 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2, and P3’s participant records. On an ongoing basis, you must maintain compliance as required in this part. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P2 and P3 that addressed the participant’s physical status determined from the medical report received from the participant’s physician. · The license holder conducted a needs assessment for P2 on April 13, 2021, but did not maintain a medical record from P2’s physician until June 17, 2021. · The license holder conducted a needs assessment for P3 on May 20, 2021, but did not maintain a medical record from P3’s physician until July 21, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not develop a written plan of care as required. The license holder failed to develop written plans of care for P2 and P3 that included§: · an update of the preliminary service plan and additional services required by the participant; and · provisions for quarterly review and quarterly 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 P2 and P3 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. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9710, subpart 7. Violation: The license holder did not offer services as required. The license holder failed to maintain a family and social history in P3’s record that was updated annually. The license holder maintained documentation that P3’s family and social history was most recently reviewed on April 26, 2021. § Corrective Action Ordered: Within 30 days of receiving this order, you must document the review of P3’s family and social history and update P3’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of an annual performance evaluation in SP1’s personnel record. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 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 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 regarding this Correction Order, please contact me as soon as possible. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6591
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