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October 27, 2023 CERTIFIED MAIL Paul Thao, Authorized Agent 5 Star Adult Day Center Inc 301 West Avenue Zumbrota, Minnesota 55992 License Number: 1103165 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Paul Thao: The Department of Human Services (DHS) is placing your license to provide adult day care services at 5 Star Adult Day Center Inc, located at 2966 White Bear Avenue North, Maplewood, Minnesota on conditional status for two years, beginning October 27, 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 May 9, 2023, DHS licensors conducted a licensing review at your facility located at 2966 White Bear Avenue North, Maplewood, Minnesota. As a result of this licensing visit, DHS determined that your program failed to comply with the laws and rules that apply to licensed adult day centers. As a result of that licensing review, a correction order was issued, dated June 27, 2023, citing 11 violations. On October 2, 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 June 27, 2023. 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 review individual abuse prevention plans; 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 staff and consultant personnel records; o Failure to provide staff annual in-service training; and o Failure to offer services, including food and nutrition, structured exercise program, and social services. · Chronicity: Your program received its license on March 4, 2020. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o April 1, 2021 Correction Order: 8 violations o June 27, 2023 Correction Order: 11 violations (5 repeat) o October 27, 2023 Conditional License (this order): 9 violations (9 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 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, you were cited for a similar violation. 2. Violation: For two participants whose records were reviewed (P1 and P3), the license holder did not include information in the participant’s written record as required. 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. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, you were cited for a similar violation. 3. 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. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, 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 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. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, you were cited for a similar violation. PERSONNEL RECORD VIOLATIONS 5. 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. Rule Violated: Minnesota Rules, part 9555.9650, item A. Repeat Violation: In a Correction Order DHS issued on June 27, 2023, you were cited for a similar violation. 6. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. 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. Rule Violated: Minnesota Rules, part 9555.9690, subpart 4. Repeat Violation: In a Correction Order DHS issued on June 27, 2023, you were cited for a similar violation. 7. Violation: For two consultants whose records were 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. Rule Violated: Minnesota Rules, part 9555.9650, item B. Repeat Violation: In a Correction Order DHS issued on June 27, 2023, you were cited for a similar violation. SERVICE AND PROGRAM VIOLATIONS 8. 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. Statute Violated: Minnesota Statutes, section 245A.14, subdivision 14, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, you were cited for a similar violation. 9. 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. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1, 4, and 7. Repeat Violation: In a Correction Order that DHS issued on June 27, 2023, you were cited for a similar violation. 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. New participants approved by DHS will be limited to no more than 10 in the first six months of your conditional license. 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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