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December 12, 2022 Allison Lewis, Authorized Agent Mount Olivet Day Services 5601 Lyndale Avenue South Minneapolis, Minnesota 55419 License Number: 809494 (Rule 223) CORRECTION ORDER Dear Allison Lewis: On December 1, 2022, a licensing review of Mount Olivet Day Services, located at 5601 Lyndale Avenue South, Minneapolis, 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 four 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. The license holder maintained documentation that the required orientation was provided to P1 on February 20, 2020; however, P1 was not admitted to the center until May 4, 2021. Corrective Action Ordered: Immediately, you must provide an orientation to P1 on your internal and external reporting procedures and PAPP. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P1), the license holder did not distribute participants’ rights, policies, and program information to participants and their caregivers as required. The license holder failed to distribute participants’ rights, policies, and program information to P1 upon P1’s admission. The license holder maintained documentation that P1 was provided participants’ rights, policies, and program information on February 20, 2020; however, P1 was not admitted to the center until May 4, 2021. Corrective Action Ordered: Immediately, you must distribute participants’ rights, policies, and program information to P1. 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 (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 a medical report in P2’s record dated within the three months prior to or 30 days after P2’s admission to the center. P2 was admitted to the center on June 23, 2022 and the license holder maintained a medical report for P2 on August 1, 2022. b. The license holder failed to include a medical report in P3’s record that included a report on P3’s physical examination, updated annually. The license holder maintained reports on P3’s physical examination dated March 11, 2021 and May 16, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P1, P2, P3, and P4), the license holder did not develop a written plan of care as required. a. The license holder failed to develop written plans of care for P1, P3, and P4 that included§: · an update of the preliminary service plan and additional services required by the participant; and · 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§: · an update of the preliminary service plan and additional services required by P2; · the staff members responsible for implementing the individual plan of care; and · the anticipated duration of the individual plan of care as written. Repeat Violation: You were cited for a similar violation in a Correction Order issued on October 21, 2020. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1, P2, P3, and P4 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. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9710, subpart 7. Violation: The license holder did not offer services as required. The license holder failed to maintain a family and social history in P1, P3, and P4’s records that were updated annually. · The license holder maintained documentation that P1’s family and social history was most recently reviewed on November 17, 2021. · The license holder maintained documentation that P3’s family and social history was most recently reviewed on September 13, 2021. · The license holder maintained documentation that P4’s family and social history was most recently reviewed on May 29, 2020. § Corrective Action Ordered: Within 30 days of receiving this order, you must document the review of P1, P3, and P4’s family and social history and update P1, P3, and P4’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9720, subpart 5. Violation: The license holder did not ensure safety as required. The license holder failed to store chemicals that were damaging to eyes or skin in an area not accessible to participants. At the time of the licensing review, chemicals were stored in an accessible location in the men’s restroom. Corrective Action Ordered: Immediately, you must store chemicals that are poisonous when swallowed or inhaled or that are damaging to eyes or skin in an area not accessible to participants. 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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