|
September 1, 2022 April Collman, Authorized Agent Adult Day Services, Inc. 620 Carr Lake Road Southeast Bemidji, Minnesota 56601 License Number: 1022091 (Rule 223) CORRECTION ORDER Dear April Collman: On August 30, 2022, a licensing review of Adult Day Services, Inc., located at 620 Carr Lake Road Southeast, Bemidji, 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 Rules, part 9555.0030. Violation: For one of four participants whose record was reviewed (P1), the license holder did not meet the requirements for positive support strategies as required. The license holder failed to incorporate positive support strategies in writing into an existing treatment, service, or other individual plan required of the license holder for P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide training to staff persons, as applicable, according to the requirements in part 9544.0090, subparts 1, and 2, and document the training according to the requirements in part 9544.0090, subpart 5; · ensure that staff persons can demonstrate competency through knowledge testing or observed skill assessment conducted by a trainer or instructor as required in part 9544.0090, subpart 4, and document the training according to the requirements in part 9544.0090, subpart 5; and · develop and implement support strategies for P1 according to the standards in part 9544.0030, subparts 2, 3, and 4. Additionally, you must: · at least every six months, evaluate with P1 whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, you must make appropriate changes; · at least every six months, evaluate with P1 whether the services support P1’s preferences, daily needs and activities, and the accomplishment of P1’s goals in accordance with Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (b), and whether the person-centered planning process compiles with Code of Federal Regulations, title 42, section 441.725, paragraph (a)(1)-(4). Based upon the results of the evaluation, you must determine whether changes are needed to enhance person-centeredness for the person, and, if so, make appropriate changes; · provide annual refresher training to all staff persons as required in part 9544.0090, subpart 3 and document the training according to part 9544.0090, subpart 5; and · maintain documentation and record keeping requirements as required in part 9544.0100. On an ongoing basis, you must maintain compliance as required in this part. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For 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). 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. 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. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not include information in the participant’s written record as required. a. The license holder failed to include an application form in P1’s record that included the telephone number of the primary person to call in case of an emergency involving P1. b. The license holder failed to include the following information in P2’s record: · 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 15, 2021. The license holder maintained a medical report for P2 on April 21, 2021; and · P2's service agreement with the center that specified the responsibilities of P2 and the center with respect to payment for and provision of services and was signed by P2 or P2's caregiver and the center director. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain the telephone number of the primary person to call in case of an emergency involving P1 in P1’s record; and · maintain a signed service agreement in P2’s record that specifies the responsibilities of P2 and the center with respect to payment for and provision of services. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. 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 September 23, 2020, but did not maintain a medical record from P2’s physician until September 24, 2020. · The license holder conducted a needs assessment for P3 on March 15, 2021, but did not maintain a medical record from P3’s physician until April 6, 2021. b. The license holder failed to develop a preliminary service plan for P1 that included P1’s nutritional needs and, where applicable, dietary restrictions. The license holder documented that P1 had a “regular diet” in P1’s preliminary service plan; however, P1’s medical report stated P1 had a “low sodium diet.” c. The license holder failed to develop a preliminary service plan for P3 that included the role of P3’s caregiver or caregivers in carrying out the service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1 and P3’s preliminary service plans to include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P1), the license holder did not develop a written plan of care as required. The license holder failed to develop a written plan of care for P1 that included§ provisions for quarterly review and quarterly revisions of the individual plan of care. The license holder maintained documentation that P1’s plan of care was most recently reviewed on April 14, 2022. §Corrective Action Ordered: Within 30 days of receiving this order, you must review P1’s plan of care and revise the plan as needed. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review to a mandated reporter as required. The license holder failed to provide SP1 and SP2 annual review of 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. Corrective Action Ordered: Immediately, you must provide the required annual review detailed above to SP1 and SP2. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 and SP2 a minimum of eight hours of in-service training annually in 2022 in the 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 training in the areas detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9720, subpart 11. Violation: The license holder did not ensure safety as required. The license holder failed to maintain a record of annual examinations for communicable disease and parasites by a licensed veterinarian for all pets that regularly visited the center. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a record of annual examinations for communicable disease and parasites by a licensed veterinarian for all pets that regularly visit the center. 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
|
