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September 26, 2022 Bee Her, Authorized Agent Hmong Elders Center, Inc. 2956 Frank Street St. Paul, Minnesota 55109 License Number: 1042535 (Rule 223) CORRECTION ORDER Dear Bee Her: On September 21, 2022, a licensing review of Hmong Elders Center, Inc., located at 1337 Rice Street, St. 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 one of three participants whose record was reviewed (P1), 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 prevention plan (PAPP) as required. The license holder failed to provide orientation to P1 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission. Corrective Action Ordered: Immediately, you must: · provide an orientation to P1 on your internal and external reporting procedures and PAPP; and · document that P1 was provided the required orientation in P1’s record. 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 orientations, 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 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 document the review of P1, P2, and P3’s IAPPs with the person’s interdisciplinary team at least annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P1, P2, and P3’s IAPPs with each 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. 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 policies and program information to participants upon admission as required. a. P1’s admission date was March 1, 2021. The license holder failed to distribute the following policies and program information to P1 upon P1’s admission to the center: · 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 of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · 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. b. The license holder failed to distribute the participants' rights to P1 upon P1’s admission to the center. Corrective Action Ordered: Immediately, you must: · distribute the policies, program information, and participants’ rights detailed above to P1; and · document the distribution of the policies, program information, and participants’ rights in P1’s record. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records that evaluates if your policies, program information, and participants’ rights were provided to the participant; and · for participants who did not receive your policies, program information, or participants’ rights, you must develop a plan detailing how your program will distribute the policies and procedures and participants’ rights 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 part. 4. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. 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 include the following information in P1’s record: · an application form signed by P1 or P1’s caregiver that included: o P1's sex and source of referral; o the name and telephone number of the person to call in case of an emergency involving P1 and the 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 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 a physical examination, updated annually; o a medical history of P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o 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; · P1's service agreement with the center that specified the responsibilities of P1 and the center with respect to payment for and provision of services and was signed by P1 or P1's caregiver and the center director; and · a statement signed by the center director and P1 at the time of P1's admission specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. b. The license holder failed to provide P1 with written notice that ensured P1 or P1's guardians had been informed of P1's right to contest the accuracy and completeness of the data maintained in the record. c. The license holder failed to include the following information in P2’s record: · an application form signed by P2 or P2’s caregiver that included P2's telephone number and source of referral; · a report on a physical examination updated annually. The most recent report on a physical examination that the license holder maintained for P2 was dated July 5, 2019. d. The license holder failed to include a medical report in P3’s record, dated within the three months prior to or 30 days after P3’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician. P3’s admission date was April 20, 2016; however, the license holder failed to maintain a medical report for P3 until June 16, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 5. 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 P1 and P3 that included§ the participant’s physical status, determined by observation, from the intake screening interview, and from the medical report received from the participant’s physician. b. The license holder failed to develop preliminary service plans for P1 and P2 that included the role of the participant’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 P2’s preliminary service plans to include the role of the participant’s caregiver or caregivers in carrying out the service plan; · 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 on site. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, 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 P1, P2, and P3 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; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; 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 P1, 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1, 4, 6, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to offer a midafternoon snack. b. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2018, 2019, 2020, 2021, and 2022. The most recent review of the license holder’s exercise program was dated June 13, 2017. c. The license holder failed to have a monthly plan for diversified daily program activities designed to meet the needs and interests of the participants and 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. d. The license holder failed to maintain a family and social history in P1, P2 and P3’s records. § Corrective Action Ordered: Immediately, you must: · offer a midafternoon snack; · develop and implement a monthly plan for diversified daily program activities as detailed above; and · maintain a family and social history in P1, P2 and P3’s records. Within 30 days of receiving this order, you must have your exercise program reviewed by a registered physical therapist. 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 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 annual performance evaluations in SP2’s personnel record. The license holder maintained documentation of annual performance evaluations dated December 20, 2016, December 13, 2021, and January 6, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this item. 9. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For two consultants whose records were reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain the following in the physical therapist and registered dietician’s personnel records: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a copy of a signed contract or letter of appointment with your physical therapist and registered dietician specifying conditions and terms of employment; and · maintain documentation that your physical therapist and registered dietician meet licensure, registration, and certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation and annual review to a mandated reporter as required. a. The license holder failed to provide SP1 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 (PAPP), 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. The license holder maintained documentation that SP1 provided direct contact on September 1, 2021 and that the required orientation was provided to SP1 on September 8, 2021. b. The license holder failed to provide SP2 annual review in 2018, 2019, 2020, and 2021 to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's PAPP, 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 orientation and annual review detailed above to SP1 and SP2. 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, 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 a minimum of eight hours of in-service training annually in 2018, 2019, 2020, and 2021 in areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP2. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder failed to establish policy and procedures related to suspected or alleged maltreatment that ensured: · an internal review was completed within 30 calendar days and that corrective action was taken as necessary to protect the health and safety of vulnerable adults when the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made; and · the internal review included an evaluation of whether the reported event was similar to past events with the vulnerable adults or the services involved. Corrective Action Ordered: Immediately, you must ensure the policy and procedures listed above are established as required in this subdivision. A copy of the policies and procedures must be posted 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. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and section 626.557, subdivision 14. Violation: The license holder did not establish a program abuse prevention plan (PAPP) as required. The license holder failed to establish a written PAPP, including: · an assessment of the population, including: o mental functioning; o the need for specialized programs of care for clients; and o the knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; · an assessment of the physical plant where the licensed services are provided, including the existence of areas in the building which are difficult to supervise; · an assessment of the environment, including the type of internal programming; and · a statement of specific measures to be taken to minimize the risk of abuse. Additionally, the license holder failed to review the PAPP at least annually. The most recent review of the PAPP was documented on July 10, 2020. Corrective Action Ordered: Within 30 days of receiving this order, you must establish a PAPP that includes the information detailed above. A copy of the PAPP must be posted 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 these subdivisions. 14. Citation: Minnesota Rules, part 9555.9720, subparts 2, 7, and 8. Violation: The license holder did not ensure safety as required. a. The license holder failed to post a list of emergency numbers next to a non-coin operated telephone. b. The license holder failed to ensure furniture was in good repair. At the time of the licensing review, licensors observed two massage chairs with torn cushions and many couches with stains on the arm rests and cushions. c. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint. At the time of the licensing review, peeling paint was observed throughout the center and loose plaster was observed in the women’s restroom. d. The license holder failed to ensure rugs had nonskid backing throughout the center. Corrective Action Ordered: Immediately, you must: · post emergency phone numbers, including 911, next to a non-coin operated telephone; · ensure all furniture used by participants is in good repair; · ensure all areas used by participants are free from loose plaster and peeling paint; and · ensure all rugs have nonskid backing. 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. 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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