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December 15, 2022 Betaleham Walle, Authorized Agent Smart Choice Adult Daycare Center LLC 521 Cedar Avenue South Minneapolis, Minnesota 55454 License Number: 1094784 (Rule 223) CORRECTION ORDER Dear Betaleham Walle: On December 8, 2022, a licensing review of Smart Choice Adult Daycare Center LLC., located at 521 Cedar Avenue, 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 2, paragraph (b). Violation: For two of four participants whose records were reviewed (P3 and P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P3 as part of P3’s initial individual program plan or service plan within 30 days of P3’s admission. P3’s admission date was June 15, 2022; and the license holder developed an IAPP for P3 on October 18, 2022. b. The license holder failed to develop an IAPP for P4 as part of P4’s initial individual program plan or service plan. P4’s admission date was June 30, 2022 and the license holder developed an IAPP for P4 on October 27, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. 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 an application form in P1’s participant record that included P1’s source of referral. b. The license holder failed to include the following information in P2’s record: · an application form that included: o P2's source of referral; and o the name and telephone number of P2’s physician or medical provider; · a medical report, dated within the three months prior to or 30 days after P2’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician. P2’s admission date was August 12, 2021; however, the license holder maintained a medical report for P2 dated March 24, 2022. c. The license holder failed to include the following information in P3’s record: · an application form that included: o P3’s source of referral; o the name and telephone number of P3’s physician or medical provider; · a medical report, 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 June 15, 2022; however, the license holder failed to maintain a medical report for P3 until August, 1, 2022.
d. The license holder failed to include an application form in P4’s participant record that included P4’s source of referral. 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. On an ongoing basis, you must maintain compliance as required in this part. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P2, P3, and P4), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P2, P3, and P4 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. 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. The license holder failed to develop written plans of care for P1, P2, P3, and P4 that included§: · 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; and · the anticipated duration of the individual plan of care as written. §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 30 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For three of three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain SP3’s job description in SP3’s personnel record. b. The license holder failed to maintain documentation of annual performance evaluations in SP1’s personnel record. c. The license holder failed to maintain documentation of annual performance evaluations in SP2’s personnel record. The license holder maintained documentation of an annual performance evaluation dated July 9, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP3’s personnel record; and · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 6. 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 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. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1 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 menus for all meals and snacks were approved by a registered dietitian and met all applicable state rules and laws and United States Department of Agriculture regulations. c. The license holder failed to maintain a family and social history in P2, P3 and P4’s records. d. The license holder failed to maintain a family and social history in P1’s record that was updated annually. The license holder maintained documentation that P1’s family and social history was most recently reviewed December 1, 2021. § Corrective Action Ordered: Within 30 days of receiving this order, you must: · offer a midafternoon snack; · ensure your menus for all meals and snacks have been approved by a registered dietician; · maintain family and social histories in P2, P3 and P4’s records; and · document the review of P1’s family and social history and update P1’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Rules, part 9555.9720, subparts 8 and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure the areas used by participants were free from debris and peeling paint. b. The license holder failed to have written plans for emergencies caused by fire that included: · Identification of primary and secondary exits; · Identification of building evacuation routes; and · Instructions on location of fire extinguishers. Corrective Action Ordered: Immediately, you must: · ensure all areas used by participants are free from debris and peeling paint; and · post your emergency plans in a visible place in the center. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d). Violation: The license holder did not post a copy of the internal and external reporting policies and procedures in a prominent location in the program as required. Corrective Action Ordered: 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, in a prominent location in the program. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and section 626.557, subdivision 14. Violation: The license holder did not establish a PAPP as required. The license holder failed to establish a written PAPP that included an assessment of the existence of areas in the building which are difficult to supervise. Additionally, the license holder failed to review the PAPP at least annually. The most recent review was documented on April 1, 2017. 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. On an ongoing basis, you must maintain compliance as required in these subdivisions. 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 your licensor, Desiree Tiller, at 651-431-4622. Jill Slaikeu, Unit Manager Licensing Division Office of Inspector General
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