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August 23, 2022 Christopher Dougherty, Authorized Agent Elim Oasis Adult Day Health Care 112 North 7th Avenue Princeton, Minnesota 55371 License Number: 1003436 (Rule 223) CORRECTION ORDER Dear Christopher Dougherty: On August 17, 2022, a licensing review of Elim Oasis Adult Day Health Care, located at 112 North 7th Avenue, Princeton, 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 two of two participants whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop IAPPs for P1 and P2 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop IAPPs for P1 and P2 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 and P2’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 two participants whose records were reviewed (P1 and P2), the license holder did not include information in the participant’s written record as required. a. The license holder failed to include the following information in P1’s record: · an application form that included the telephone number of P1's physician or medical provider; and · a medical report dated within the three months prior to or 30 days after P1’s admission to the center. P1 was admitted to the center on April 4, 2022 and the license holder maintained a medical report for P1 on May 31, 2022. Additionally, the license holder failed to maintain a medical report for P1 that included 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 9, 2021 and the license holder maintained a medical report for P2 on November 24, 2021; and · P2's service agreement with the center signed by the center director. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’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 (P1 and P2), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P1 and P2 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 P1 on April 4, 2022, but did not maintain a medical record from P1’s physician until May 31, 2022. · The license holder conducted a needs assessment for P2 on March 9, 2021, but did not maintain a medical record from P2’s physician until November 24, 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 (P1 and P2), the license holder did not develop a written plan of care as required. The license holder failed to develop written plans of care for P1 and P2 that included§: · an update of the preliminary service plan and additional services required by the participant; · short and long term objectives for the participant stated in concrete, measurable and time specific outcomes; and · the anticipated duration of the individual plan of care as written. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1 and P2 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 9555.9650, item A. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of an annual performance evaluation in SP2’s personnel record. The most recent documentation of an annual performance evaluation was dated August 21, 2020. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP2 and maintain documentation of the performance evaluation in SP2’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP2 in-service training annually in the following areas: · areas related to care of center participants, including provision of medication assistance and review of parts 9555.8000 to 9555.8500, 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP2. On an ongoing basis, you must maintain compliance as required in this subpart. 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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