February 27, 2023

Mang Chu-Yang-Heu, Authorized Agent

Hmong Minnesota Senior Center

2905 Country Drive

Little Canada, Minnesota 55117

License Number: 1049124 (Rule 223)

CORRECTION ORDER

Dear Mang Chu-Yang-Heu:

On January 26, 2023, a licensing review of Hmong Minnesota Senior Center, located at 2905 Country Drive, Little Canada, 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.

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 that included:

· the time of day that the recipient was dropped off; and

· the time of day that the recipient was picked up.

Corrective Action Ordered: Immediately, you must maintain documentation as required in this subdivision. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a).

Violation: For three of four participants whose records were reviewed (P1, P3 and P4), 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, P3 and P4 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission.

Corrective Action Ordered: Immediately, you must:

· provide an orientation to P1, P3 and P4 on your internal and external reporting procedures and PAPP; and

· document that P1, P3 and P4 were provided the orientation in P1, P3 and P4’s records.

Within 30 days of receiving this order, you must:

· complete an audit of all participants’ records for orientation on your internal and external reporting procedures and PAPP; and

· for participants that have not received the required orientations, you must develop a plan detailing how the orientation will be provided 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 these subdivisions.

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

Violation: For 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 develop IAPPs for P1, P2, P3 and P4 as part of the initial individual program plan or service plan.

Corrective Action Ordered: Immediately, you must develop IAPPs for P1, P2, P3 and P4. Within 30 days of receiving this order, you must:

· review P1, P2, P3 and P4’s IAPPs with the 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.

4. Citation: Minnesota Rules, part 9555.9640.

Violation: For four participants whose records were reviewed (P1, P2, P3 and P4), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required.

a. The license holder failed to distribute the participants’ rights to P1, P2, P3 and P4, including:

· the right to participate in developing one's own plan of care;

· the right to refuse care or participation;

· the right to physical privacy during care or treatment;

· the right to confidentiality of participant records; and

· the right to present grievances regarding treatment or care in accordance with part 9555.9640, item D.

b. The license holder failed to distribute the following policies and program information to P1, P2, P3 and P4:

· the scope of the programs, services, and care offered by the center;

· a description of the population to be served by the center;

· a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering;

· the center's policy on and arrangements for providing transportation;

· the center's policy on providing meals and snacks;

· the center's fees, billing arrangements, and plans for payment;

· the center's policy governing the presence of pets in the center;

· the center's policy on smoking in the center;

· types of insurance coverage carried by the center;

· a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section;

· a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act;

· the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and

· the telephone number of the department's licensing division.

Corrective Action Ordered: Immediately, you must:

· distribute the policies and program information and participants’ rights detailed above to P1, P2, P3 and P4; and

· document the distribution of the policies and program information and participants’ rights in the participant’s record.

Within 30 days of receiving this order, you must:

· complete an audit of all participants’ records that evaluates if your policies and program information and participants’ rights were provided to the participant; and

· for participants who did not receive your policies and program information or participants’ rights, you must develop a plan detailing how your program will distribute the policies and program information and participants’ rights to the participant and their caregiver 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 part.

5. 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 the following information in P1’s record:

· an application form that included:

o P1's date of admission or readmission and living arrangement;

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;

· attendance and participation reports and progress notes that are recorded at least monthly;

· notes on special problems, medication changes, and need for medication assistance; and

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

b. The license holder failed to include the following information in P2’s record:

· an application form that included:

o P2's date of admission or readmission and living arrangement; and

o the name and telephone number of the person to call in case of an emergency involving P2 and the name and number of another person to call if that person cannot be reached;

· 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, that included:

o a report on a physical examination, updated annually;

o a medical history of P2;

o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2;

o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and

o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants;

· P2's service agreement with the center that specified the responsibilities of P2 and the center with respect to payment for and provision of services and was signed by P2 or P2's caregiver and the center director;

· attendance and participation reports and progress notes that are recorded at least monthly;

· notes on special problems, medication changes, and need for medication assistance; and

· a statement signed by the center director and P2 at the time of P2's admission specifying the basis on which P2 determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.

c. The license holder failed to include the following information in P3’s record:

· an application form that included:

o P3's date of admission or readmission and living arrangement;

o the name and telephone number of the person to call in case of an emergency involving P3 and the name and number of another person to call if that person cannot be reached; and

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, that included:

o a report on a physical examination, updated annually;

o a medical history of P3;

o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P3;

o a release signed by the physician indicating whether P3 may engage in a structured exercise program; and

o documentation that P3 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants;

· P3's service agreement with the center that specified the responsibilities of P3 and the center with respect to payment for and provision of services and was signed by P3 or P3's caregiver and the center director;

· attendance and participation reports and progress notes that are recorded at least monthly;

· notes on special problems, medication changes, and need for medication assistance; and

· a statement signed by the center director and P3 at the time of P3's admission specifying the basis on which P3 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.

d. The license holder failed to include the following information in P4’s record:

· an application form that included P4’s date of admission;

· a medical report, dated within the three months prior to or 30 days after P4’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 P4;

o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P4; and

o documentation that P4 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants;

· P4's service agreement with the center that specified the responsibilities of P4 and the center with respect to payment for and provision of services and was signed by P4 or P4's caregiver and the center director;

· attendance and participation reports and progress notes that are recorded at least monthly; and

· a statement signed by the center director specifying the basis on which P4 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.

e. The license holder failed to provide P1, P2, P3 and P4 with written notices that ensured the participant or their guardians or caregivers had been informed of the participant’s right to contest the accuracy and completeness of the data maintained in the record.

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

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

Violation: For four participants whose records were reviewed (P1, P2, P3 and P4), the license holder did not complete initial service planning as required.

a. The license holder failed to conduct needs assessments for P1, P2, P3 and P4 that included:

· the participant's psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization);§

· the participant's functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and

· 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, P2, and P3 that included:

· §scheduled days of the participant’s attendance at the center;

· transportation arrangements for getting the participant to and from the center;

· the participant’s nutritional needs and, where applicable, dietary restrictions;

· the role of the participant’s caregiver or caregivers in carrying out the service plan; and

· services and activities in which the participant would take part immediately upon admission.

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

· conduct needs assessments for P1, P2, P3 and P4 as detailed above;

· develop preliminary service plans for P1, P2, and P3 that include the information and specifications detailed above;

· 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.

7. 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§:

· 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, 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.

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

8. 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.

The license holder failed to maintain documentation of annual performance evaluations in SP1 and SP2’s personnel records in 2020, 2021 and 2022.

Corrective Action Ordered: Within 30 days of receiving this order, you must complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’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.

9. Citation: Minnesota Rules, part 9555.9650, item B.

Violation: For one consultant whose record was reviewed, the license holder did not include all required information in the personnel record.

The license holder failed to maintain the following in the physical therapist’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 physical therapist specifying conditions and terms of employment; and

· maintain documentation that your physical therapist 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.

10. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review to a mandated reporter as required.

The license holder failed to provide SP1 and SP2 annual review in 2021 and 2022 to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder’s program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

Corrective Action Ordered: Immediately, you must provide the required annual review detailed above to SP1 and SP2. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision.

11. Citation: Minnesota Rules, part 9555.9690, subpart 4.

Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required.

The license holder failed to provide SP1 and 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 SP1 and SP2 training in the areas detailed above and document the completed training in the staff person’s record;

· complete an audit of all personnel records to ensure all staff persons have received the required annual in-service training detailed above; and

· for staff persons that have not received the required annual in-service training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 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 subpart.

12. Citation: Minnesota Rules, part 9555.9690, subpart 2, item C.

Violation: The license holder did not provide staff coverage of the center as required.

The license holder failed to have a person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times in the center when participants were present. At the time of the licensing review on January 26, 2023, the license holder did not have any staff persons trained in basic first aid and certified in cardiopulmonary resuscitation.

Corrective Action Ordered: Immediately, you must have a person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times in the center when participants were present. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart.

13. 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 met all applicable state rules and laws and United States Department of Agriculture regulations.

b. The license holder failed to maintain a record indicating the menu for all meals served for at least six months.

c. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2020, and 2021 and 2022. The only documented review of the license holder’s exercise program was dated January 29, 2020.

d. The license holder failed to maintain family and social histories in P3 and P4’s records.

§

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

· maintain menus for all meals and snacks that are approved by a dietician and meet all applicable state rules and laws and Unities States Department of Agriculture regulations;

· ensure your physical therapist provides consultation and review of your exercise program; and

· maintain family and social histories in P3 and P4’s records.

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

14. Citation: Minnesota Rules, part 9555.9720, subparts 3 and 9.

Violation: The license holder did not ensure safety as required.

a. The license holder failed to have emergency phone numbers of each participant’s caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician readily available at the center.

b. The license holder failed to rehearse the fire escape plan at least four times in 2020, 2021 and 2022.

Corrective Action Ordered: Immediately, you must:

· ensure emergency phone numbers of each participant’s caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician are readily available at the center; and

· rehearse your fire escape plan and record the date of the rehearsal in the file of emergency plans.

Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts.

15. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and section 626.557, subdivision 14.

Violation: The license holder did not establish a program abuse prevention plan (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;

· an assessment of the physical plant where the licensed services are provided, including:

o the condition and design of the building as it related to the safety of the persons; and

o the existence of areas in the building which are difficult to supervise; and

· a statement of specific measures to be taken to minimize the risk of abuse.

Additionally, the license holder failed to review the PAPP at least annually. The most recent review was documented on November 30, 2012.

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.

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 your licensor, Desiree Tiller, at 651-431-4622.

Brittany Raddatz, Supervisor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/