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October 6, 2023 Bee Moua, Authorized Agent Asian Community Center LLC 710 Arcade Street License Number: 1063125 (Rule 223) CORRECTION ORDER Dear Bee Moua: On August 28, 2023, a licensing review of Asian Community Center LLC, located at 710 Arcade Street, 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 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. Corrective Action Ordered: Immediately, you must maintain documentation of actual attendance for each adult day service recipient. On an ongoing basis, you must maintain compliance as required in this item. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one of three 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 review P1’s IAPP with P1’s interdisciplinary team at least annually. Corrective Action Ordered: Within 30 days of receiving this order, you must review P1’s IAPP with the person’s interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. 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 SP1’s job description in SP1’s personnel record. b. The license holder failed to maintain the following in SP2’s personnel record: · SP2’s job description; and · documentation of annual performance evaluations in 2021, 2022, and 2023. c. The license holder failed to maintain documentation of annual performance evaluations in 2020, 2021, and 2022 in SP3’s personnel record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP1 and SP2’s personnel records; and · complete performance evaluations for SP2 and SP3 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. 4. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For one consultant whose record was reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the physical therapist’s personnel record. 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. On an ongoing basis, you must maintain compliance as required in this item. 5. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide in-service training annually as required. a. The license holder failed to provide SP2 a minimum of eight hours of in-service training annually in 2023 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. b. The license holder failed to provide SP3 a minimum of eight hours of in-service training annually in 2020, 2021, 2022 and 2023 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 SP2 and SP3. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9710, subparts 1 and 4. 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 license review, the thermostat in the refrigerator indicated a temperature of 44 degrees. b. The license holder failed to offer a midafternoon snack. c. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. Corrective Action Ordered: Immediately, you must: · offer a midafternoon snack; and · ensure your refrigerator maintains a temperature of 40 degrees or less. Within 30 days of receiving this order, you must have your physical therapist provide consultation and review of your exercise program. On an ongoing basis, you must maintain compliance as required in these subparts. 7. Citation: Minnesota Rules, part 9555.9720, subpart 9. Violation: The license holder did not ensure safety as required. 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: On an ongoing basis, you must maintain compliance as required in this subpart. 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 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 regarding this Correction Order, please your licensor, Alexandra Devick, at 651-431-4626. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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