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October 19, 2023
Touney Xiong, Authorized Agent Universal Adult Day Care Center LLC 1454 Kingswood Pond Overlook Eagan, Minnesota 55122 License Number: 1081612 (Rule 223) CORRECTION ORDER Dear Touney Xiong: On October 5, 2023, a licensing review of Universal Adult Day Care Center LLC, located at 7322 Lakeland Avenue North, Brooklyn Park, 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: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For one of six participants whose record was reviewed (P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to review P2’s IAPP quarterly as part of the review of the program plan or service plan. Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s IAPP with P2 and their interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision and subpart. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1.
Violation: For five participants whose records were reviewed (P1, P2, P3, P4, and P5), the license holder did not include information in the participant’s written record as required.
a. The license holder failed to maintain participation and progress notes that were recorded at least monthly in P1, P2, and P3’s record. b. The license holder failed to maintain medical reports in P4 and P5’s records dated within the 3 months prior to or 30 calendar days after the participant’s admission to the center. P4 was admitted on February 10, 2023 and the license holder maintained a report for P4 on May 3, 2023. c. P5 was admitted on March 27, 2023 and the license holder maintained a report for P5 on September 25, 2023.
Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For four participants whose records were reviewed (P2, P4, P5, and P6), the license holder did not complete initial service planning as required. a. The license holder failed to develop a preliminary service plan for P2 within 30 days of P2’s admission. P2 was admitted to the center on August 5, 2022 and the license holder maintained documentation of a preliminary service plan for P2 dated February 20, 2023. b. The license holder failed to: · conduct a needs assessment for P4 that addressed P4’s physical status using information from the medical report received from the participant’s physician. The license holder conducted P4’s needs assessment on February 24, 2023; however, the license holder did not receive the medical report from P4’s physician until May 3, 2023; and · develop a preliminary service plan for P4 that included P4’s nutritional needs and, where applicable, dietary restrictions. c. The license holder failed to: · conduct a needs assessment for P5 that addressed P5’s physical status using information from the medical report received from the participant’s physician. The license holder conducted P5’s needs assessment on April 10, 2023; however, the license holder did not receive the medical report from P5’s physician until September 25, 2023; and · develop a preliminary service plan for P5 that included P5’s nutritional needs and, where applicable, dietary restrictions. d. The license holder failed to conduct a needs assessment for P6 that included the following: · P6's psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization);§ · P6's functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · P6's physical status, determined by observation, from the intake screening interview, and from the medical report received from the participant's physician. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P4, P5, and P6 as detailed above; · update P4 and P5’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. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P2, P4, P5, and P6), 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 P2 that included provisions for quarterly review and quarterly revisions of the individual plan of care. b. The license holder failed to develop written plans of care for P4 and P5 that included an update of the preliminary service plan and additional services required by P4 and P5. c. The license holder failed to develop a written plan of care for P6 that included: · an update of the preliminary service plan and additional services required by P6; and · the anticipated duration of the individual plan of care as written. Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Ordered: § Within 30 days of receiving this order, you must: · review P2’s written plan of care and document the review; · update P4, P5, and P6’s written plans of care to 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. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9650, item A.
Violation: For three of five staff persons whose record were reviewed (SP1, SP2, and SP4), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain a job description in SP1 and SP2’s personnel records. b. The license holder failed to maintain documentation of an annual performance evaluation in SP4’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 a performance evaluation for SP4 and maintain documentation of the evaluation in SP4’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 7. 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 Required: 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. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP4 and SP5), the license holder did not provide in-service training annually as required. The license holder failed to provide SP4 and SP5 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. Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP4 and SP5 training in the areas detailed above and document the completed training in the SP4 and SP5’s record; · complete an audit of all personnel records to ensure all staff persons have received the required annual in-service training detailed above; and · for staff persons that have not received the required annual in-service training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. The license holder failed to offer a midmorning snack. Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Ordered: Immediately, you must offer a midmorning snack. On an ongoing basis, you must maintain compliance as required in this subpart.
10. Citation: Minnesota Rules, part 9555.9720, subparts 8 and 9. Violation: The license holder did not meet safety requirements. a. The license holder failed to ensure rugs had nonskid backing. b. The license holder failed to post written plans for emergencies in a visible place in the center. Repeat Violation: In a Correction Order that DHS issued on May 20, 2021, you were cited for a similar violation. Corrective Action Required: Immediately, you must: · ensure rugs have nonskid backing; and · post a copy of your written plans for emergencies in a visible place in your center. On an ongoing basis, you must maintain compliance as required in these subparts. 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, Katie Johnson, at 651-431-4113. Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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