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October 20, 2023 CERTIFIED MAIL Laxmi Pokhrel, Authorized Agent Diversity Adult Daycare Services Inc 360 Skillman Avenue East Maplewood, Minnesota 55117-2057 License Number: 1099211 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Laxmi Pokhrel: The Department of Human Services (DHS) is placing your license to provide adult day center services at Diversity Adult Daycare Services Inc, located at 93 Little Canada Road West, Little Canada, Minnesota on conditional status for two years, beginning October 20, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On July 26, 2022, DHS licensors conducted a licensing review at your facility located at 93 Little Canada Road, Little Canada, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed adult day centers, citing 15 violations. On September 21, 2023, a follow-up licensing review was made to your facility. DHS determined that you had not complied with the corrective action ordered in the correction order dated July 28, 2022. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to ensure safety; o Failure to maintain attendance record documentation; o Failure to maintain participants’ written records; o Failure to complete initial service planning; o Failure to develop written plans of care; o Failure to maintain personnel records; o Failure to provide training to mandated reporters; o Failure to provide staff orientation to the center; o Failure to provide staff annual in-service training; o Failure to offer services; and o Failure to comply with licensing requirements for remote adult day services. o Failure to post emergency plans in a visible place in the center. · Chronicity: Your program received its license on January 1, 2020. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o July 28, 2022 Correction Order: 15 violations o October 20, 2023 Conditional License (this order): 13 violations (10 repeat) · Severity: Many of the violations that led to the Order of Conditional license relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For three of three participants whose records were reviewed (P2 and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop IAPPs for P2 and P3 as part of the participants initial program plan or service plan. · P2 was admitted on February 1, 2022. The license holder maintained documentation that P2’s IAPP was developed on December 1, 2022. · P3 was admitted on May 30, 2023. As of the date of the licensing review on September 21, 2023, the license holder had not developed an IAPP for P3. b. The license holder failed to review P1, P2 and P3’s IAPPs quarterly as part of the review of the program plan or service plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. 2. Violation: For one participant whose record was reviewed (P1), the license holder did not distribute policies and procedures to the participant and their caregiver upon admission as required. The license holder failed to distribute the telephone number of the DHS Licensing Division, 651-431-6500, to P1 upon admission. Rule Violated: Minnesota Rules, part 9555.9640. Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. 3. 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 maintain the following information in P1’s record: · a medical record in P1’s record dated within the 3 months prior to or 30 calendar 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 an indication of dietary restrictions and medication regimen, including the need for medication assistance, that applied to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, and would endanger the health of other participants; · participation reports and progress notes that are recorded at least monthly; · notes on special problems, medication changes, and need for medication assistance; and · a discharge summary. b. The license holder failed to maintain the following information in P2’s record: · an application form that included: o P2’s source of referral; and o the name and telephone number of a secondary person to call in case of an emergency involving P2; · a medical report dated within the three months prior to or 30 days after P2’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 indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants; · participation reports and progress notes that are recorded at least monthly. c. The license holder failed to include the following information in P3’s record: · an application form that included: o P3’s date of admission, living arrangement and source of referral; and o the name and telephone number of the person to call in case of emergency involving P3 and the name and number of a secondary person to call in case of an emergency involving P3; · a medical report dated within the three months prior to or 30 days after P3’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 physician examination; o a medical history of P3; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P3; o a release signed by the physician indicating whether P3 may engage in a structured exercise program; and o documentation that P3 is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants; · P3's service agreement with the center that specified the responsibilities of P3 and the center with respect to payment for and provision of services and was signed by P3 or P3's caregiver and the center director; · participation reports and progress notes that are recorded at least monthly; · notes on special problems, medication changes, and need for medication assistance; and · a copy of the center’s statement on participants’ rights, signed by P3 or P3’s caregiver that indicated P3 was informed of rights. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. 4. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder failed to: · conduct a needs assessment for P1 that addressed P1’s physical status determined from the medical report received from P1’s physician. The license holder conducted a needs assessment for P1 on January 24, 2022 but did not maintain a medical record from P1’s physician until July 15, 2022; and · develop a preliminary service plan for P1 that included: o P1’s nutritional needs and, where applicable, dietary restrictions; and o services and activities in which P1 would take part immediately upon admission. b. The license holder failed to: · conduct a needs assessment for P2 that included P2’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P2’s physician; · the license holder failed to develop a preliminary service plan for P2 based on the assessment in item A and coordinated with other plans of services for P2 within 30 days of P2’s admission that included: o scheduled days of P2’s attendance at the center; o P2’s nutritional needs and, where applicable, dietary restrictions; and o services and activities in which P2 would take part immediately upon admission. c. The license holder failed to: · conduct a needs assessment for P3 that included P3’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P3’s physician; and · develop a preliminary service plan for P3 that included: o transportation arrangements for getting P3 to and from the center; o P3’s nutritional needs and, where applicable, dietary restrictions; and o services and activities in which P3 would take part immediately upon admission. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. PERSONNEL RECORD VIOLATIONS 5. Violation: For one of one staff person whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to maintain the following in SP1’s personnel record: · SP1’s job description; and · an employment application or resume. Rule Violated: Minnesota Rules, part 9555.9650, item A. Repeat Violation: In a Correction Order DHS issued on July 28, 2022, you were cited for a similar violation. 6. Violation: For two consultants whose record 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 physical therapist’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. Rule Violated: Minnesota Rules, part 9555.9650, item B. Repeat Violation: In a Correction Order DHS issued on July 28, 2022, you were cited for a similar violation. 7. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP1 orientation 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, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. Repeat Violation: In a Correction Order DHS issued on July 28, 2022, you were cited for a similar violation. 8. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least 4 hours of supervised orientation before the employee worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Rule Violated: Minnesota Rules, part 9555.9690, subpart 3. Repeat Violation: In a Correction Order DHS issued on July 28, 2022, you were cited for a similar violation. SERVICE AND PROGRAM VIOLATIONS 9. Violation: The license holder did not meet licensing requirements for remote adult day services. The license holder failed to maintain approval by the commissioner prior to providing remote adult day services to participants. Statute Violated: Minnesota Statutes, 254A.71, subdivisions 1 and 2. 10. 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. Statute Violated: Minnesota Statutes, section 245A.14, subdivision 14, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. 11. 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 nurse provided consultation and review of health services at least monthly. The only documented review of the license holder’s exercise program was dated January 24, 2022. c. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. The only documented review of the license holder’s exercise program was dated February 19, 2019. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1, 3, and 4. Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were cited for a similar violation. SAFETY VIOLATIONS 12. Violation: The license holder did not meet safety requirements. a. The license holder failed to post written plans for emergencies in a visible place. b. 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. Rule Violated: Minnesota Rules, part 9555.9720, subpart 9. Repeat Violation: In a Correction Order that DHS issued on July 28, 2022, you were previously found in violation of this same rule. POLICY AND PROCEDURES VIOLATIONS 13. 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective action required You must correct the violations as described above. If you fail to demonstrate substantial compliance with adult day care requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the adult day care licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving adult day care services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. Additionally, while the license is on conditional status, you must maintain documentation of the names of individuals you’ve provided the notification to and the date the individual was provided the notification. 2. Within 30 days of receiving this order, you must: · develop a quality assurance audit tool to ensure personnel records include all required documentation and training; · develop a quality assurance audit tool to ensure participant records include all required information; and · submit the quality assurance audit tools to your DHS licensor for approval. 3. Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you must complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you must submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 4. During the first 30 days of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new participants to your program. The notification to your licensor must include the name of the participant, the participant’s anticipated date of admission, documentation of compliance with term 1 of your conditional license, and your plan to meet compliance with individual service planning requirements. 5. During the first six months of your conditional license, you may not provide remote adult day services to any participant. After this time the Commissioner will determine if you will be allowed to provide remote adult day services based upon the results of the compliance monitoring visits. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Desiree.B.Tiller@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Desiree Tiller YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two from that date. You continue to be required to comply with all adult day care laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Adult day care centers are required to follow Minnesota Statutes, chapters 245A and 245C and Minnesota Rules, parts 9550.9600 to 9555.9730. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, HCBS Unit Supervisor, at 651-431-6591. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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