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November 3, 2022 Ashley Bormann, Authorized Agent Bethesda Day Break 901 Willmar Avenue Southeast Willmar, Minnesota 56201 License Number: 810468 (Rule 223) CORRECTION ORDER Dear Ashley Bormann: On November 2, 2022, a licensing review of Bethesda Day Break, located at 901 Willmar Avenue Southeast, Willmar, 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 four of 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 review P1, P2, P3, and P4’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained documentation that P1’s IAPP was reviewed in March 2021, August 2022, and September 2022. · The license holder maintained documentation that P2’s IAPP was reviewed in January 2022, August 2022, and October 2022. · The license holder maintained documentation that P3’s IAPP was reviewed in May 2019 and August 2022. · The license holder maintained documentation that P4’s IAPP was reviewed in April 2019 and August 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9544.0080. Violation: For one participant whose record was reviewed (P1), the license holder did not provide notice on the emergency use of manual restraint policy as required. Although the license holder provided P1 and P1’s legal representative notice of the license holder’s policy about emergency use of manual restraint at the time of P1’s service initiation, the license holder failed to obtain a written acknowledgment from P1, or P1's legal representative, that P1 had been notified of the policy. Corrective Action Ordered: Within 30 days of receiving this order, you must obtain written acknowledgement from P1 and P1’s legal representatives that P1 has been notified of your policy on the emergency use of manual restraint. On an ongoing basis, you must maintain compliance as required in this part. 3. 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 an application form in P1’s record that was signed by P1 or P1’s caregiver and included the telephone number of P1's physician. 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; 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 November 8, 2021 and the license holder maintained a medical report for P2 on December 29, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this part. 4. 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 using information from the medical report received from the participant’s physician. · The license holder conducted P1’s needs assessment on March 16, 2021; however, the license holder did not receive the medical report from P1’s physician until March 22, 2021. · The license holder conducted P2’s needs assessment on November 8, 2021; however, the license holder did not receive the medical report from P2’s physician until December 19, 2021. § Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, P2, and P4), 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§ the anticipated duration of the individual plan of care as written. b. The license holder failed to develop a written plan of care for P2 that included§: · short and long term objectives for P2 stated in concrete, measurable and time specific outcomes; and · the anticipated duration of the individual plan of care as written. c. The license holder failed to develop a written plan of care for P4 that included§ short and long term objectives for P4 stated in concrete, measurable and time specific outcomes. §Corrective Action Ordered: Within 30 days of receiving this order, you must develop written plans of care for P1, P2, and P4 that include the information listed above. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one of two staff persons 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 2022 in areas related to care of center participants, including 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. 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: Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit P.O. Box 64953 Saint Paul, MN 55164-0953 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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