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March 17, 2023 Nay Aung Moe, Authorized Agent Karen Myanmar Senior Center 1741 City Heights Drive Maplewood, Minnesota 55117-2318 License Number: 1088220 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Nay Aung Moe: On January 10, 2023, as a result of a licensing review, a Correction Order was issued to Karen Myanmar Senior Center, located at 1059 Viking Drive East, Maplewood, Minnesota. You were ordered to take corrective action for violations determined under citations 1 through 16. On March 2, 2023, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 2, 4, 6, 7, 8, 10, 11, 13, 15 and 16 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) and section 626.557, and subdivision 14. 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). a. Although the license holder developed an IAPP for P1, the license holder failed to ensure P1’s IAPP contained an accurate individualized assessment of: · P1's susceptibility to abuse by other individuals, including other vulnerable adults; · P1's risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults. P1’s Coordinated Services and Supports Plan (CSSP) dated March 10, 2021 stated “if [s/he] does not like or get what [s/he] wants, [s/he] will become agitated and aggressive toward others.” P1’s CSSP dated March 10, 2022 stated “[P1] will meet with [their] psychiatrist and hopefully get new medications to calm [them] so [s/he] can be less aggressive.” The license holder failed to include this assessment in P1’s IAPP. b. The license holder failed to review P1, P2, P3, and P4’s IAPPs quarterly as part of the review of the program plan or service plan. · P1, P2, and P4’s IAPPs were not dated; therefore, it was unable to be determined when P1, P2, and P4’s IAPPs were reviewed. · The license holder maintained documentation that P3’s IAPP was most recently reviewed on September 14, 2020. Corrective Action Ordered: Immediately, you must update P1’s IAPP to include an individualized assessment of: · P1's susceptibility to abuse by other individuals, including other vulnerable adults; · P1's risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults. 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. License Holder Response: The license holder reviewed P2, P3, and P4’s IAPP with participants’ interdisciplinary team. DHS Response: 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; · P1's risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults. Additionally, the license holder failed to review P1’s IAPP with P1’s interdisciplinary team. Corrective Action Ordered: Within 15 days of receiving this order, you must: · develop an IAPP for P1 that includes an individualized assessment of: o P1's susceptibility to abuse by other individuals, including other vulnerable adults; o P1's risk of abusing other vulnerable adults; and o statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults; and · review P1’s IAPP with P1’s interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9544.0070, subpart 1 and Minnesota Statutes, section 245D.061, subdivision 9. Violation: The license holder did not develop a policy and procedures that promoted service recipient rights and protected health and welfare during the emergency use of manual restraint as required. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a policy and procedures on the emergency use of manual restraint as stated above; · provide notice to P1 and P1’s legal representative of your policy and procedures on the emergency use of manual restraint as required in part 9544.0080. · The notice must: o inform P1 of their rights under Minnesota Statutes, section 245D.04; and o be in writing; and · obtain written acknowledgement from P1 and P1’s legal representative that P1 has been notified. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part. License Holder Response: The license holder did not take corrective action as ordered. DHS Response: The license holder did not develop a policy and procedures that promoted service recipient rights and protected health and welfare during the emergency use of manual restraint as required. Corrective Action Ordered: Within 15 days of receiving this order, you must: · develop a policy and procedures on the emergency use of manual restraint as stated above; · provide notice to P1 and P1’s legal representative of your policy and procedures on the emergency use of manual restraint as required in part 9544.0080. · The notice must: o inform P1 of their rights under Minnesota Statutes, section 245D.04; and o be in writing; and · obtain written acknowledgement from P1 and P1’s legal representative that P1 has been notified. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Rules, part 9555.9660, subpart 1. 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. P1 was admitted to the center on April 9, 2018. 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 days after P1’s admission to the center that included a report on a physical examination, updated annually. The license holder maintained a medical report for P1 on February 11, 2019 and a report on P1’s physical examination on July 29, 2021; · participation reports and progress notes that were recorded at least monthly; 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. The license holder maintained the required statement for P1 on May 15, 2018. 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 and source of referral; and o the telephone number of P2's physician; · 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; · participation reports and progress notes that were recorded at least monthly; and · a statement signed by the center director and P2 at the time of P2's admission specifying the basis on which P2 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. P2 was admitted to the center on August 2, 2021 and the license holder maintained the required statement for P2 on September 20, 2021. c. The license holder failed to include the following information in P3’s record: · an application form that included P3's date of admission and source of referral; · 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; · participation reports and progress notes that were recorded at least monthly; 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. P3 was admitted to the center on September 11, 2020 and the license holder maintained the required statement for P3 on October 6, 2020. d. The license holder failed to include the following information in P4’s record: · an application form that included: o P4's living arrangement, telephone number and source of referral; o the name and telephone number of the person to call in case of emergency involving P4 and name and number of another person to call if that person cannot be reached; and o the name and telephone number of P4’s physician or medical provider; · 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; o a release signed by the physician indicating whether P4 may engage in a structured exercise program; 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; · participation reports and progress notes that were recorded at least monthly; and · a statement signed by the center director and P4 at the time of P4's admission specifying the basis on which P4 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. 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. License Holder Response: The license holder updated P1 and P3’s written record as ordered. The license holder maintained the following in P2’s record: · an application form that included the telephone number of P2’s physician; · a medical report, signed by a physician assistant 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; and · participation reports and progress notes that were recorded at least monthly. Additionally, the license holder maintained the following in P4’s record: · an application form that included: o P4's living arrangement, telephone number and source of referral; o the name and telephone number of the person to call in case of emergency involving P4 and name and number of another person to call if that person cannot be reached; and o the name and telephone number of P4’s physician or medical provider; · a report on a physician exam, dated February 2, 2023; and · a statement signed by the center director and P4 specifying the basis on which P4 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.
DHS Response: The license holder failed to include an application form in P2’s written record that included P2’s admission date and source of referral. Additionally, the license holder failed to maintain the following in P4’s record: · a medical report, signed by a physician assistant or signed by a physician assistance or registered nurse and cosigned by a physician, that included: o a medical history of P4; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P4; o a release signed by the physician indicating whether P4 may engage in a structured exercise program; 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; and · participation reports and progress notes that were recorded at least monthly. Corrective Action Ordered: Within 15 days of receiving this order, you must maintain all information detailed above in P2 and P4’s participant records. On an ongoing basis, you must maintain compliance as required in this part. 7. 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: · 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. c. The license holder failed to develop a preliminary service plan for P4 that included: · scheduled days of P4’s attendance at the center; · P4’s nutritional needs and, where applicable, dietary restrictions; · the role of P4’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P4 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; · develop preliminary service plans for P1, P2, P3, and P4 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. License Holder Response: The license holder conducted needs assessments and developed preliminary service plans for P1, P2, and P3 as ordered. Additionally, the license holder developed a preliminary service plan for P4 that included the following: · scheduled days of P4’s attendance at the center; · the role of P4’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P4 would take part immediately upon admission. DHS Response: The license holder failed to conduct a needs assessment for P4. Additionally, the license holder failed to develop a preliminary service plan for P4 that included P4’s nutritional needs and, where applicable, dietary restrictions. Corrective Action Ordered: Within 15 days of receiving this order, you must: · conduct a needs assessment for P4; and · update P4’s preliminary service plan to include P4’s nutritional needs and, where applicable, dietary restrictions. On an ongoing basis, you must maintain compliance as required in this subpart. 8. 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; · 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 detailed 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.
· 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. The license holder developed a written plan of care for P4 that included: · 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. DHS Response: The license holder failed to develop a written plan of care for P1 and P3 that included: · §short and long term objectives for participants’ 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. The license holder failed to develop a written plan of care for P2 that included the staff members responsible for implementing the individual plan of care. The license holder failed to develop a written plan of care for P4 that included: · short and long term objectives for participants’ stated in concrete, measurable and time specific outcomes; and · the staff members responsible for implementing the individual plan of care. Corrective Action Ordered: Within 15 days of receiving this order, you must develop a written plan of care for P1, P2, P3, and P4 that includes the information listed above. On an ongoing basis, you must maintain compliance as required in this subpart. 10. 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 the following information in SP1 and SP2’s personnel records: · job descriptions; and · documentation of annual performance evaluations. b. The license holder failed to maintain a job description in SP3’s personnel record. c. The license holder failed to document that SP2 and SP3 completed the orientation to the center required in part 9555.9690, subpart 3. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain job descriptions in SP1, SP2, and SP3’s personnel records; · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record; and · document the completion of orientation to the center for SP2 and SP3. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. License Holder Response: The license holder maintained job descriptions in SP1, SP2 and SP3’s personnel records. The license holder completed a performance evaluation for SP2 and maintained documentation of the evaluation in SP2’s personnel record. Additionally, the license holder maintained documentation of the completion of orientation to the center for SP3. DHS Response: The license holder failed to complete a performance evaluation for SP1. Additionally, the license holder failed to maintain documentation of the completion of orientation to the center for SP2. Corrective Action Ordered: Within 15 days of receiving this order, you must: · complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’s personnel record; and · document the completion of orientation to the center for SP2. On an ongoing basis, you must maintain compliance as written in this item. 11. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For two 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 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 registered nurse and 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. License Holder Response: The license holder maintained the following in the physical therapist’s personnel record: · a copy of a signed contact 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. DHS Response: 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. Corrective Action Ordered: Within 15 days of receiving this order, you must maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the registered nurse’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 13. 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 the required in-service training 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 subpart. License Holder Response: The license holder provided SP1 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. The license holder maintained documentation that SP2 received six hours of training in areas related to care of center participants, including provision of medication assistance. DHS Response: The license holder failed to provide SP2 a minimum of eight hours of in-service training and review of parts 9555.9600 to 9555.9730. Corrective Action Ordered: Within 15 days of receiving this order, you must provide SP2 training and review of parts 9555.9600 to 9555.9730. On an ongoing basis, you must maintain compliance as required in this subpart. 15. Citation: Minnesota Rules, part 9555.9720, subpart 2 and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to post a list of emergency phone numbers, including 911, next to a telephone. b. The license holder failed to record the dates of fire drill rehearsals in the file of emergency plans. The license holder recorded the dates of fire drill rehearsals in participants’ records. Corrective Action Ordered: Immediately, you must post a list of emergency phone numbers, including 911, next to a telephone. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. License Holder Response: The license holder recorded the dates of fire drill rehearsals in the file of emergency plans. DHS Response: The license holder failed to post a list of emergency phone numbers, including 911, next to a telephone. Corrective Action Ordered: Immediately, you must post a list of emergency phone numbers, including 911, next to a telephone. On an ongoing basis, you must maintain compliance as required in this subpart. 16. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). 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 need for specialized programs of care 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.
Additionally, the license holder failed to post a copy of the PAPP in a prominent location in the program. 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 this subdivision. License Holder Response: The license holder did not complete corrective action as ordered. DHS Response: The license holder failed to establish a written PAPP, including: · an assessment of the population, including the need for specialized programs of care 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.
Additionally, the license holder failed to post a copy of the PAPP in a prominent location in the program. Corrective Action Ordered: Within 15 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 this subdivision. 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, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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