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October 14, 2022 CERTIFIED MAIL Pay Soung, Authorized Agent Twin Cities Adult Day Services LLC 848 Aspen Circle Little Canada, Minnesota 55109 License Number: 1076130 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Pay Soung: The Department of Human Services (DHS) is placing your license to provide at Twin Cities Adult Day Services LLC, 2231 11th Avenue East, St. Paul, on conditional status for two years, beginning October 14, 2022. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On July 6, 2022, DHS licensors conducted a licensing review at your facility at 2231 11th Avenue East, St. Paul, Minnesota. As a result of this licensing visit, DHS determined that your program failed to comply with the laws and rules that apply to your licensed adult day center. As a result of that licensing review a correction order was issued, dated July 11, 2022, citing 14 violations. On September 20, 2022, a follow-up licensing review was made to your facility. DHS determined that you had not complied with the corrective action ordered in the correction order dated July 11, 2022. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to provide staff coverage of center; o Failure to develop and maintain individual abuse prevention plans; o Failure to maintain written records for participants; o Failure to complete initial service planning; o Failure to develop written plans of care for participants; o Failure to maintain personnel records as required; o Failure to post policies and procedures related to the internal and external reporting of suspected or alleged maltreatment as required; o Failure to establish and post a program abuse prevention plan as required; o Failure to offer social services as required; and o Failure to ensure safety requirements. · Chronicity: Your program received its license on March 10, 2019. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o July 11, 2022 Correction Order: 14 violations o July 29, 2022 Order to Pay a Fine 1 background study violation o October 14, 2022 Conditional License (this order): 10 violations (9 repeat) · Severity: Many of the violations that led to the Order of Conditional license relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. STAFF COVERAGE OF CENTER 1. Violation: The license holder did not provide staff coverage of the center as required. On September 20, 2022, while DHS was conducting a licensing inspection, the license holder failed to designate a staff member to supervise the center in the absence of the director. · 11:35am: DHS licensors arrived at your program and asked if the center director was available. The staff person that greeted DHS licensors stated the center director (SP1) was not at the center but would be returning to the center in 20 minutes. DHS licensors asked the staff person if there was someone at the center that could assist licensors with accessing records and the staff person said the center director was the only staff with access to records. · 12:05pm: The authorized agent arrived at the center. DHS licensors requested assistance from the authorized agent with gaining access to records. The authorized agent stated the center director (SP1) was the only one that had access to the office where records were stored. The authorized agent called the center director at this time. · 12:15pm: The center director arrived at the center. · 12:25pm: DHS licensors requested access to records and were given access. The license holder’s failure to designate a staff member to supervise the center in the absence of the director was demonstrated through the license holder’s failure to provide access to the following documentation without the center director’s presence at the center: · personnel records; · participant records; · program policies and procedures; · health service documentation; and · structured exercise documentation. Statute Violated: Minnesota Rules, part 9555.9690, subpart 2, item A. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same statute. Corrective Action Required: Immediately, you must develop a plan to ensure that there is a designated staff member to supervise the center in the absence of the director. This plan must include a method to ensure the designated staff member has access to the documentation detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. PARTICIPANT RECORD VIOLATIONS 2. 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 review P1’s IAPP with P1’s interdisciplinary team at least annually. b. The license holder failed to develop IAPPs for 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same statute. Corrective Action Required: Within 30 days of receiving this order, you must: · develop IAPPs for 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 IAPP 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. 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 participant record: · an application form that included: o P1’s telephone number; 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; and · participation reports and progress notes that are recorded at least monthly. b. The license holder failed to include the following information in P2’s participant record: · an application form that included: o P2’s telephone number; o the name and telephone number of the person to call in case of an emergency involving P2 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P2’s physician or medical provider; · a medical report that included indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; · participation reports and progress notes that are recorded at least monthly; and · notes on special problems or on changes needed in medication and on the need for medication assistance. c. The license holder failed to include the following information in P3’s record: · an application form that included: o P3's telephone number; o the name and telephone number of the person to call in case of an emergency involving P3 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P3's physician or medical provider; · a medical report that included documentation that P3 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · participation reports and progress notes that are recorded at least monthly; and · notes on special problems or on changes needed in medication and on the need for medication assistance. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same rule. Corrective Action Required: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2, and P3’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 4. 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 a needs assessment for P1 that included: · P1’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P1’s physician. b. The license holder failed to conduct needs assessments for P2 and P3 that included: · the participant’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · §the participant’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · §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 a preliminary service plan for P3 that included: · scheduled days of P3’s attendance at the center; and · role of P3’s caregiver or caregivers in carrying out the service plan. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022], you were previously found in violation of this same rule. Corrective Action Required: Within 30 days of receiving this order, you must: • conduct needs assessments for P1, P2, and P3 as detailed above; • develop a preliminary service plan for P3 that includes the information and specifications detailed above; • 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. On an ongoing basis, you must maintain compliance as required in this subpart. 5. 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. a. The license holder failed to develop a written plan of care for P1 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 anticipated duration of the individual plan of care as written; and · provisions for quarterly review and quarterly revisions of the individual plan of care. a. 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; · 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. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same rule. Corrective Action Required: Within 30 days of receiving this order, you must: · develop written plans of care for P1, P2, and P3 that include the information detailed 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 30 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. STAFF PERSON RECORD VIOLATIONS 6. Violation: For one of one staff person 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. Rule Violated: Minnesota Rules, part 9555.9650, item A. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same rule. Corrective Action Required: 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. POLICY AND PROCEDURES VIOLATIONS 7. Violation: The license holder did not post a copy of the internal and external reporting policies and procedures and program abuse prevention plan in a prominent location in the program as required. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d) and subdivision 2, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same statute. Corrective Action Required: Immediately, you must post a copy of your internal and external reporting policies and procedures, including the telephone number of the common entry point as defined in section 626.5572, subdivision 5, and your program abuse prevention plan in a prominent location in the program. On an ongoing basis, you must maintain compliance as required in these subdivisions. 8. Violation: The license holder did not establish a PAPP as required. The license holder failed to establish a written PAPP, including: · an assessment of the population, including: o the need for training of staff to meet identified individual needs; 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: o the condition and design of the building as it related to the safety of the persons; and o the existence of areas in the building which are difficult to supervise; and · an assessment of the environment, including the type of grounds and terrain surrounding the building. Additionally, the license holder failed to review the PAPP at least annually. The most recent review was documented on May 1, 2021. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and section 626.557, subdivision 14. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same statute. Corrective Action Required: 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. On an ongoing basis, you must maintain compliance as required in these subdivisions. SERVICE AND PROGRAM VIOLATIONS 9. Violation: The license holder did not offer services as required. The license holder failed to maintain a family and social history in P1, P2, and P3’s records. Rule Violated: Minnesota Rules, part 9555.9710, subpart 7. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same rule. Corrective Action Required: Within 30 days of receiving this order, you must maintain a family and social history in P1, P2, and P3’s records. On an ongoing basis, you must maintain compliance as required in this subpart. SAFETY VIOLATIONS 10. Violation: The license holder did not ensure safety as required. a. The license holder failed to have a first aid kit that contained a first aid manual. b. The license holder failed to have a list of emergency numbers, including 911, posted next to a non-coin operated telephone. c. The license holder failed to have emergency phone numbers of each participant’s caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician readily available at the center. d. The license holder failed to store chemicals that were poisonous when swallowed or that were damaging to eyes or skin in an area not accessible to participants. On September 20, 2022, chemicals were being stored accessible to participants in both restrooms. e. The license holder failed to ensure the use of razor blades by persons was allowed only under supervision. On September 20, 2022, a razor blade was observed being stored on a shelf in the men’s restroom. The restrooms were not supervised at all times by staff persons. f. The license holder failed to have written plans for emergencies caused by fire that included instructions on location and use of fire extinguishers. g. The license holder failed to record the dates of the rehearsals of the fire escape plan in the file of emergency plans. Rule Violated: Minnesota Rules, part 9555.9720, subparts 1, 2, 3, 5, and 9. Repeat Violation: In a Correction Order that DHS issued on July 11, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately, you must: · ensure your first aid kit contains a first aid manual and sterile bandages; · post emergency phone numbers, including 911, next to a non-coin operated telephone; · ensure emergency phone numbers of each participant’s caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician are readily available at the center; · store chemicals in an area that is not accessible to participants; · ensure the use of scissors, knives, matches, razor blades, and other potentially hazardous materials by persons is allowed only under supervision; and · develop written plans for emergencies caused by fire that include the information detailed above. On an ongoing basis, you must maintain compliance as required in these subparts. Corrective action required You must correct the violations as described above. If you fail to demonstrate substantial compliance with adult day service requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the adult day service licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving adult day care services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · develop a quality assurance audit tool to ensure personnel records include all required documentation and training; · develop a quality assurance audit tool to ensure participant records include all required information; and · submit the quality assurance audit tools to your DHS licensor for approval. 3. Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you must complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you must submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 4. During the first six months of your conditional license, no new admissions will be allowed. After this time the Commissioner will determine if new admissions will be allowed based upon the results of the compliance monitoring visits. Submissions required as part of a corrective action ordered must be sent to your Licensor at: Commissioner, Department of Human Services ATTN: Brittany Raddatz Office of Inspector General Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all adult day service laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Adult day centers are required to follow Minnesota Statutes, chapters 245A and 245C and Minnesota Rules, parts 9550.9600 to 9555.9730. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6544. Sincerely,  Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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