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March 10, 2023 Song Vang, Authorized Agent Metro Senior Center LLC 2930 Costa Lane Little Canada, Minnesota 55117-1167 License Number: 1042514 (Rule 223) CORRECTION ORDER Dear Song Vang: On March 8, 2023, a licensing review of Metro Senior Center LLC located at 948 Rice Street, Saint 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.65, subdivision 2, paragraph (b). Violation: For one of two participants whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop an IAPP for P1 that included an individualized assessment of: · P1’s susceptibility to abuse by other individuals, including other vulnerable adults; and · P1’s risk of abusing other vulnerable adults. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1 that includes an individualized assessment of the information detailed above; · 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P1), the license holder did not distribute policies and program information to the participant and their caregiver upon admission as required. a. P1’s admission date was April 1, 2022. The license holder failed to distribute the following policies and program information to P1 and P1’s caregivers: · 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. b. The license holder failed to provide P1 and P1’s caregiver with the participant’s rights including the right to present grievances regarding treatment or care. Corrective Action Ordered: Immediately, you must: · distribute the policies, program information and participants’ rights listed above to P1 and their caregiver; and · document the distribution of the policies, program information and participants’ rights in P1’s record. 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 (P1 and P2), 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 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 · a medical report, dated within the three months prior to or 30 days after P1’s admission to the center. P1’s admission date was April 1, 2022 and the license holder maintained a medical report for P1 on June 21, 2022. b. 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’s admission date was December 16, 2019 and the license holder maintained a medical report for P2 on August 16, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1. On an ongoing basis, you must maintain compliance as required in this part. 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. The license holder failed to conduct a needs assessment for P1 that included the participant’s physical status determined from the medical report received from the participant’s physician. The license holder conducted P1’s needs assessment prior to obtaining P1’s medical report. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s needs assessment to include P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received by P1’s physician. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P1), the license holder did not develop a written plan of care as required. 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 participant; · short- and long-term objectives for the person stated in concrete, measurable, and time specific outcomes; 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 a written plan of care for P1 that includes 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. 6. 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 SP2’s job description in SP2’s personnel record. b. The license holder failed to maintain documentation of annual performance evaluations in SP1 and SP2’s personnel records. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP2’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. 7. 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 and physical therapist’s personnel records. 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, physical therapist, and registered dietician specifying conditions and terms of employment; and · maintain documentation that your registered dietician meet licensure, registration, and certification requirements required to perform the services On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 a minimum of eight hours of in-service training annually in 2021 and 2022 in the following areas: · areas related to care of center participants, including provision of medication assistance and review of parts 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. a. The license holder failed to ensure the refrigerator had a temperature of 40 degrees Fahrenheit or less. At the time of the licensing review, the thermostat in the refrigerator indicated a temperature of 50 degrees Fahrenheit. b. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietitian and met all applicable state rules and laws and US Department of Agriculture regulations. Corrective Action Ordered: Immediately, you must provide services as stated above. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish a written program abuse prevention plan (PAPP) as required. a. The license holder failed to establish a written PAPP that included 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. b. The license holder failed to review the PAPP at least annually using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. The license holder most recently reviewed the PAPP in July 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. 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, Alexandra Devick at 651-431-4626. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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