Minnesota

December 22, 2022

Bee Her, Authorized Agent

Hmong Elders Center, Inc.

2956 Frank Street

St. Paul, Minnesota 55109

License Number: 1042535 (Rule 223)

NOTICE OF NON-COMPLIANCE

AND CORRECTION ORDER

Dear Bee Her:

On September 26, 2022, as a result of a licensing review, a Correction Order was issued to Hmong Elders Center, Inc., located at 1337 Rice Street, St. Paul, Minnesota.

You were ordered to take corrective action for violations determined under citations 1 through 7 and 9 through 14. On December 20, 2022, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 2, 4, 5, 6, 10, and 11, 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 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.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: For 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).

The license holder failed to document the review of P1, P2, and P3’s IAPPs with the person’s interdisciplinary team at least annually.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· review P1, P2, and P3’s IAPPs with each 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 failed to take corrective action as ordered.

DHS Response: The license holder failed to review P1, P2, and P3’s IAPPs with the person’s interdisciplinary team annually.

Corrective Action Ordered: Within 15 days of receiving this order, you must:

· review P1, P2, and P3’s IAPPs with each 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 30 calendar days of receiving this order.

On an ongoing basis, you must maintain compliance as required in this subdivision.

4. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 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 record:

· an application form signed by P1 or P1’s caregiver that included:

o P1's sex and source of referral;

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;

· a medical report, dated within the three months prior to or 30 days after P1’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that included:

o a report on a physical examination, updated annually;

o a medical history of P1;

o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1;

o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and

o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants;

· P1's service agreement with the center that specified the responsibilities of P1 and the center with respect to payment for and provision of services and was signed by P1 or P1's caregiver and the center director; and

· a statement signed by the center director and P1 at the time of P1's admission specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.

b. The license holder failed to provide P1 with written notice that ensured P1 or P1's guardians had been informed of P1's right to contest the accuracy and completeness of the data maintained in the record.

c. 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 telephone number and source of referral;

· a report on a physical examination updated annually. The most recent report on a physical examination that the license holder maintained for P2 was dated July 5, 2019.

d. The license holder failed to include a medical report in P3’s record, 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 April 20, 2016; however, the license holder failed to maintain a medical report for P3 until June 16, 2022.

Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts.

License Holder Response: The license holder included the following information in P1’s record:

· an application form signed by P1 that included:

o P1's sex and source of referral;

o the name and telephone number of the person to call in case of an emergency involving P1; and

o the name and telephone number of P1's physician or medical provider;

· a medical report;

· P1's service agreement with the center;

· a statement specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions; and

· documentation that P1 was provided a written notice that ensured P1 was informed of P1's right to contest the accuracy and completeness of the data maintained in the record.

Additionally, the license holder included an application form signed by P2 in P2’s record.

DHS Response: The license holder failed to include an application form in P1’s record that included the name and telephone number of the secondary person to call in case of an emergency involving P1. Additionally, the license holder failed to include the following information in P2’s record:

· an application form that included P2's telephone number and source of referral; and

· a report on a physical examination updated annually.

Corrective Action Ordered: Within 15 days of receiving this order, you must:

· update P1’s application form to include the name and telephone number of the secondary person to call in case of an emergency involving P1;

· update P2’s application form to include P2's telephone number and source of referral; and

· maintain a report on P2’s physical examination.

On an ongoing basis, you must maintain compliance as required in these subparts.

5. Citation: Minnesota Rules, part 9555.9700, subpart 2.

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 needs assessments for P1 and P3 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.

b. The license holder failed to develop preliminary service plans for P1 and P2 that included the role of the participant’s caregiver or caregivers in carrying out the service plan.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· update P1 and P2’s preliminary service plans to include the role of the participant’s caregiver or caregivers in carrying out the service plan;

· 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.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

License Holder Response: The license holder failed to take corrective action as ordered.

DHS Response: The license holder failed to develop preliminary service plans for P1 and P2 that included the role of the participant’s caregiver or caregivers in carrying out the service plan.

Corrective Action Ordered: Within 15 days of receiving this order, you must:

• update P1 and P2’s preliminary service plans to include the role of the participant’s caregiver or caregivers in carrying out the service plan;

• 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 30 calendar days of receiving this order.

On an ongoing basis, you must maintain compliance as required in this subpart.

6. Citation: Minnesota Rules, part 9555.9700, subpart 3.

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.

The license holder failed to develop written plans of care for P1, 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.

§Corrective Action Ordered: Within 30 days of receiving this order, you must:

· develop written plans of care for P1, P2, and P3 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.

Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.

License Holder Response: The license holder reviewed P2 and P3’s written plans of care.

DHS Response: 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 P1;

· short and long term objectives for P1 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.

Additionally, the license holder failed to develop written plans of care for P2 and P3 that included§: