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June 27, 2023 Paul Thao, Authorized Agent 5 Star Adult Day Center Inc 2966 White Bear Avenue North Maplewood, Minnesota 55109 License Number: 1103165 (Rule 223) CORRECTION ORDER Dear Paul Thao: On May 9, 2023, a licensing review of 5 Star Adult Day Center Inc, located at 2966 White Bear Avenue North, Maplewood, 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 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 first, middle, and last name of the recipient; · the time of day that the recipient was dropped off; and · the time of day that the recipient was picked up. Repeat Violation: In a Correction Order that DHS issued on April 1, 2021, you were cited for a similar violation. Corrective Action Ordered: Immediately and on an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one of three participants whose record was reviewed (P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to review P3’s IAPP quarterly as part of the review of the program plan or service plan. The license holder maintained documentation that P3’s IAPP was most recently reviewed on March 14, 2022. Repeat Violation: In a Correction Order that DHS issued on April 1, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P3’s IAPP with P3 and P3’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. 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 and P3’s records: · a medical report, dated within the three months prior to or 30 days after the participant’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 physical examination, updated annually; o a medical history of the participant; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to the participant; o a release signed by the physician indicating whether the participant may engage in a structured exercise program; and o documentation that the participant was free from communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would otherwise endanger the health of other participants; · participation reports and progress notes that were recorded at least monthly; and · notes on special problems or on changes needed in medication and on the need for medication assistance. b. The license holder failed to include a medical report in P2’s record that included a report on P2’s physical examination. Repeat Violation: In a Correction Order that DHS issued on April 1, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2 and P3’s participant records. 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 two participants whose records were reviewed (P1 and P2), the license holder did not complete initial service planning as required. a. The license holder failed to conduct a needs assessment for P1 that included 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 conduct a needs assessment for P2 that addressed P2’s physical status determined from the medical report received from P2’s physician. The license holder conducted a needs assessment for P2 on May 16, 2022 but did not maintain a medical record from P2’s physician until May 21, 2022. Repeat Violation: In a Correction Order that DHS issued on April 1, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1 and P2’s needs assessments to include information from the medical report received from P1 and P2’s physician. 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. The license holder failed to develop written plans of care for P1, P2, and P3 that included provisions for quarterly review and quarterly revision of the individual plan of care.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P1, P2, and P3’s written plan of care with P1, P2, and P3 and revise the plan of care, if necessary; · 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 offer a midmorning snack. b. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2021, 2022, and 2023. c. The license holder failed to maintain a family and social history for P3 that was updated annually. The license holder most recently reviewed P3’s family and social history on July 7, 2021. Repeat Violation: In a Correction Order that DHS issued on April 1, 2021, you were cited for a similar violation. Corrective Action Ordered: Immediately, you must offer a midmorning snack. Within 30 days of receiving this order, you must review: · have your registered physical therapist provide consultation and review of your exercise program; and · update P3’s family and social history. Compliance 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 one of two staff persons whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of an annual performance evaluation in SP1’s personnel record in 2021, 2022 and 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’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 Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual review to a mandated report as required. The license holder failed to provide SP1 annual review in 2021, 2022 and 2023 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 (PAPP), 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. 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. a. The license holder failed to provide SP1 a minimum of eight hours of in-service training annually in 2021, 2022 and 2023 in areas related to care of center participants, including provision of medication assistance and review of parts 9555.9600 to 9555.9730. b. The license holder failed to provide 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. SP2’s hire date was December 2019. SP2 received their annual in-service training in May 2021, February 2022, and March 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required annual training to SP1 on the topics above as required. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as written in this subpart. 10. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For one consultant whose record was reviewed, the license holder did not include information in the personnel record as required. a. The license holder failed to maintain the following information 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. b. The license holder failed to maintain documentation that the registered dietician 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 and registered dietician meet licensure, registration, and certification requirements required to perform services. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as written in this item. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish and enforce their program abuse prevention plan (PAPP) as required. The license holder failed to ensure the license holder’s governing body or the governing body’s delegated representative reviewed the PAPP at least annually. The license holder most recently documented a review of the PAPP on January 29, 2020. Corrective Action Ordered: Within 30 days of receiving this order, you must review your PAPP using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. Compliance with this order will be reviewed on site. 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: 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, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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