|
October 5, 2022 MayPa Heu, Authorized Agent Daphne Elder Center 1983 Sloan Place Maplewood, Minnesota 55117 License Number: 1102638 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear MayPa Heu:
On August 11, 2022, as a result of a licensing review, a Correction Order was issued to Daphne Elder Center, located at 1983 Sloan Place, Maplewood, Minnesota. You were ordered to take corrective action for violations determined under citations 2 through 15. On October 4, 2022, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 2, 4, and 15, it was determined that corrective action has not been achieved. As a result, this Notice of Noncompliance and 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 a 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 of state and federal laws and rules was 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. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For four participants whose records were reviewed (P1, P2, P3, and P4), 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, P3, and P4 as part of the participant’s initial individual program plan or service plan. Corrective Action Ordered: Immediately, you must develop IAPPs for P1, P2, P3, and P4. Within 30 days of receiving this order, you must: · review P1, P2, P3, and P4’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. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. License Holder Response: The license holder developed IAPPs for P1, P2, P3, and P4. DHS Response: The license holder failed to review P1, P2, P3, and P4’s IAPPs with the person’s interdisciplinary team. Corrective Action Ordered: Within 15 days of receiving this order, you must review P1, P2, P3, and P4’s IAPPs with the person’s interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For four participants whose records were reviewed (P1, P2, P3, and P4), 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, P2, and P4’s records: · an application form signed by the participant or their caregiver that included the participant’s source of referral; · a medical report dated within the three months prior to or 30 days after the participant’s admission to the center; o P1 was admitted to the center on July 26, 2021 and the license holder maintained a medical report for P1 that was dated December 9, 2021; o P2 was admitted to the center on September 16, 2021 and the license holder maintained a medical report for P2 that was dated February 3, 2022; and o P4 was admitted to the center on November 30, 2021 and the license holder maintained a medical report for P4 that was dated May 24, 2022; · attendance and participation reports and progress notes that are recorded at least monthly; and · a statement signed by the center director and the participant at the time of the participant's admission specifying the basis on which the participant was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. b. 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 source of referral; · 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 December 9, 2020 and the license holder maintained a medical report for P2 that was dated February 10, 2021. Additionally, the license holder failed to maintain a medical report for P2 that included: o a report on a physical examination, updated annually in 2022; and o a medical history of P2; · attendance and participation reports and progress notes that are recorded at least monthly; and · a statement signed by the center director and P2 at the time of P2's admission specifying the basis on which P2 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2, P3, and P4’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. License Holder Response: The license holder maintained application forms, medical reports, and monthly participation reports and progress notes in P1, P2, P3, and P4’s participant records. DHS Response: The license holder failed to include a statement in P1, P2, P3, and P4’s participant records that was signed by the center director and the participant specifying the basis on which the participant was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. Corrective Action Ordered: Within 15 days of receiving this order, you must maintain a statement in P1, P2, P3, and P4’s participant records that is signed by the center director and the participant specifying the basis on which the participant was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. On an ongoing basis, you must maintain compliance as required in this subpart. 15. Citation: Minnesota Rules, part 9555.9720, subparts 1, 8, and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to have a first aid kit that included an ice bag or cold pack. b. The license holder failed to ensure rugs had nonskid backing. c. The license holder failed to rehearse the fire escape plan at least four times in 2020 and 2021. Corrective Action Ordered: Immediately, you must: · include an ice bag or cold pack in your first aid kit; · ensure all rugs have a nonskid backing; and · rehearse your fire escape plan and document the date of the rehearsal in your 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. License Holder Response: The license holder included a cold pack in their first aid kit and rehearsed their fire escape plan. DHS Response: The license holder failed to ensure rugs had nonskid backing. Corrective Action Ordered: Within 15 days of receiving this order, you must ensure all rugs in the center have a nonskid backing. 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, section 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 Licensor Licensing Division Office of Inspector General 651-431-6591
|
