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December 29, 2022 Woyneshet Bedorek, Authorized Agent Unity Adult Day Care Center LLC 853 Minnehaha Avenue West St. Paul, Minnesota 55104 License Number: 1083330 (Rule 223) CORRECTION ORDER Dear Woyneshet Bedorek: On December 19, 2022, a licensing review of Unity Adult Day Care Center LLC, located at 1566 Thomas Avenue West, St. Paul, 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.14, subdivision 14, paragraph (c). Violation: The license holder did not meet the requirements for attendance record documentation as required. The license holder failed to maintain documentation of actual attendance for each adult day service recipient for which the license holder was reimbursed by a governmental program. The license holder maintained attendance records for all participants that documented all participants arrived at the center at 9:00am and departed at 3:00pm. DHS licensors asked the center director if these times were accurate and the center director stated people may arrive five to ten minutes before or after the times documented on the attendance record. Corrective Action Ordered: On an ongoing basis, you must maintain documentation of actual attendance, including the time of day that the recipient was dropped off and the time of day that the recipient was picked up. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two of three participants whose records were reviewed (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 P2’s IAPP quarterly as part of the review of the program plan or service plan. The license holder maintained documentation that P2’s IAPP was reviewed on September 15, 2021, January 12, 2022, June 9, 2022 and September 21, 2022. b. The license holder failed to develop an IAPP for P3 as part of P3’s initial individual program plan or service plan. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. Corrective Action Ordered: Immediately, you must develop an IAPP for P3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. 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 that included P1’s source of referral; · a medical report dated within the three months prior to or 30 calendar days after P1’s admission to the center. P1 was admitted to the center on February 28, 2022 and the license holder maintained a medical report for P1 on April 20, 2022; and · participation reports and progress notes that were recorded at least monthly. b. The license holder failed to include the following information in P2’s record: · a medical report that included a report on a physical examination, updated annually. The license holder maintained a report on P2’s physical examination that was most recently dated September 2, 2021; and · participation reports and progress notes that were recorded at least monthly. c. The license holder failed to include participation reports and progress notes that were recorded at least monthly in P3’s record. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1’s application form to include P1’s source of referral; and · maintain a report on P2’s physical examination in P2’s record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For one participant whose record was reviewed (P1), the license holder did not complete initial service planning as required. a. The license holder failed to conduct a needs assessment for P1 within 30 days after P1’s admission. P1 was admitted to the center on February 28, 2022 and the license holder conducted a needs assessment for P1 on June 1, 2022. b. The license failed to develop a preliminary service plan for P1 within 30 days after P1’s admission. Although the license holder maintained documentation of a preliminary service plan in P1’s record, the plan was not dated; therefore, it was unable to be determined when the preliminary service plan was developed. Additionally, the license holder failed to develop a preliminary service plan for P1 that included the role of P1’s caregiver or caregivers in carrying out the service plan. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s preliminary service plan to include the role of P1’s caregiver or caregivers in carrying out the service plan. Compliance with this order will be reviewed on site. 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 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 P1; and · short and long term objectives for P1 stated in concrete, measurable and time specific outcomes. 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; · short and long term objectives for P2 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. c. The license holder failed to develop a written plan of care for P3 that included§: · an update of the preliminary service plan and additional services required by P3; · short and long term objectives for P3 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. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. §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. 6. Citation: Minnesota Rules, part 9555.9710, subparts 1, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to: · ensure menus for all meals and snacks were approved by a registered dietitian; and · maintain a record indicating the menu for all meals served for at least six months. b. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly between January 4, 2022 and December 13, 2022. c. The license holder failed to maintain a family and social history in P2’s record that was updated annually. The license holder maintained documentation of P2’s family and social history that was not dated; therefore, it was unable to be determined if it was reviewed annually. d. The license holder failed to maintain a family and social history in P3’s record. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. § Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure menus for all meals and snacks are approved by a registered dietician; · document the review of P2’s family and social history and update P2’s family and social history, if applicable; and · maintain documentation of a family and social history in P3’s record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 7. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain accurate documentation of SP1’s completed orientation to the center. The license holder maintained a document titled “Adult Day Services Staff Orientation Checklist” in SP1’s personnel record and this document indicated SP1 completed 20 hours of training on April 14, 2022. b. The license holder failed to maintain documentation of an annual performance evaluation in SP2’s personnel record. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on September 30, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP2 and maintain documentation of the evaluation in SP2’s personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For three consultants whose records were reviewed, the license holder did not include all required information in the personnel record. a. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the registered nurse’s personnel record. b. The license holder failed to maintain the following in the registered dietician’s personnel record: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a copy of a signed contract or letter of appointment with your registered nurse and registered dietician specifying conditions and terms of employment; and · maintain documentation that your registered dietician meets licensure, registration, and certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 9. 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, including: · an assessment of the population, including the knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; and · an assessment of the physical plant where the licensed services are provided, including the existence of areas in the building which are difficult to supervise. 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. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions. 10. Citation: Minnesota Rules, part 9555.9720, subpart 9. Violation: The license holder did not ensure safety as required. The license holder failed to accurately record the dates of fire drill rehearsals in the file of emergency plans. The license holder documented that fire drills were completed on February 18, 2022 (Saturday), June 18, 2022 (Saturday), and September 18, 2022 (Sunday); however, according to the center’s licensed days and hours of operation and the center director, the center did not operate on Saturdays or Sundays. Corrective Action Ordered: 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: 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 questions regarding this Correction Order, please contact your licensor, Alexandra Devick, at 651-431-4626. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General
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