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August 7, 2023 Sheng Hang Amerson, Authorized Agent Lifestyle Adult Day Center LLC 995 University Avenue West Suite 109 Saint Paul, Minnesota 55104 License Number: 1064601 (Rule 223) CORRECTION ORDER Dear Sheng Hang Amerson: On July 27, 2023, a licensing review of Lifestyle Adult Day Center LLC, located at 995 University Avenue West, 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.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). The license holder failed to provide orientation to P1 and P2 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission. · P1 was admitted to the center on May 1, 2023. The license holder provided P1 the required orientation on May 22, 2023. · P2 was admitted to the center on March 2, 2023. The license holder provided P2 the required orientation on March 28, 2023. Corrective Action: On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1.
a. The license holder failed to include the following information in P1’s record: · an application form that included: o P1’s source of referral; and o the name and telephone number of the person to call in case of emergency involving P1 and name and number of another person if that person cannot be reached; · 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; 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 of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · notes on special problems, medication changes, and need for medication assistance. b. The license holder failed to include the following information in P2’s record: · an application form that included P2’s source of referral; and · a medical report dated with the 3 months prior to or 30 calendar days after P2’s admission to the center. P2 was admitted to the center on January 27, 2023 and the license holder maintained a medical report for P2 dated June 27, 2023. c. The license holder failed to include the following information in P3 and P4’s records: · medical reports, dated within the three months prior to or 30 days after the participant’s admission to the center signed by a physician, or 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 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; o documentation that the participant 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 · notes on special problems, medication changes, and need for medication assistance. 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 record. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose record 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 P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P1’s physician; and · develop a preliminary service plan for P1 that included the role of P1’s caregiver or caregivers in carrying out the service plan. 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 March 28, 2023 but did not maintain a medical report from P2’s physician until June 27, 2023; and · develop a preliminary service plan for P2 that included: o the role of P2’s caregiver or caregivers in carrying out the service plan and services; and o services and activities in which P2 will take part in immediately upon admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1 and P2 as detailed above; · update P1 and P2’s preliminary service plans to 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. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), 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 and P2 that included an update of the preliminary service plan and additional services required by P1 and P2. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1 and P2 that include an update of the preliminary service plan and additional services required by the participant; · 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 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, subpart 3. Violation: The license holder did not offer health services as required. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly prior to March 2023. Additionally, the license holder failed to ensure health services included: · monitoring a person’s health status and reporting changes to the person’s caregiver, physician, and center director; · educating and counseling persons on good health practices; · maintaining a listing of professional health resources available for referrals as needed by people; · developing policies and monitoring procedures for participant self-administration of medications for training unlicensed personnel who provide medication assistance; and · supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 2, item C. Corrective Action Ordered: Immediately, you must provide health services as detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9730, subpart 3. Violation: The license holder did not equip restrooms with signal systems as required. The license holder failed to equip restrooms used by participants with a mechanism that participants could use to signal staff members by light or by sound if participants needed assistance. Corrective Action Ordered: Immediately, you must ensure restrooms used by participants are equipped with a mechanism that participants can use to signal staff members by light or by sound if participant need assistance. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not review 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 June 4, 2019. 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. 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 regarding this Correction Order, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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