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May 1, 2023 Woyneshet Bedorek, Authorized Agent Unity Adult Day Care Center LLC Saint Paul, Minnesota 55104 License Number: 1083330 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Woyneshet Bedorek: On December 19, 2022 as a result of a licensing review, a Correction Order was issued to Unity Adult Day Care Center LLC located at 1566 Thomas Avenue West, Saint Paul, Minnesota. You were ordered to take corrective action for violations determined under citations 1 through 10. On April 20, 2023, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 3, 5, 8 and 9 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. 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.
DHS Response: The license holder failed to include participation reports and progress notes that were recorded at least monthly in P1, P2, and P3’s records. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 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. License Holder Response: The license holder developed a written plan of care for P1 that included§ an update of the preliminary service plan and additional services required by P1. The license holder developed a written plan of care for P2 that included§: · an update of the preliminary service plan and additional services required by P2; · 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 P3 that included§: · an update of the preliminary service plan and additional services required by P3; · short and long term objectives 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. DHS Response: The license holder failed to develop a written plan of care that included short and long term objectives for P1 and P2 stated in concrete, measurable and time specific outcomes. Corrective Action Ordered: Within 15 days of receiving this order, you must develop a written plan of care for P1 and P2 that includes short and long term objectives for P1 and P2 stated in concrete, measurable and time specific outcomes. 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. · 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 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 part. 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. License Holder Response: The license holder did not take corrective action as ordered. · 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 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 these subdivisions. 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, Alexandra Devick, at 651-431-4626. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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