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January 26, 2024 Pay Soung, Authorized Agent Twin Cities Adult Day Services LLC 848 Aspen Circle Little Canada, MN 55109 License Number: 1076130 (Rule 223) CORRECTION ORDER Dear Pay Soung: On December 13, 2023, a licensing review of Twin Cities Adult Day Services LLC, located at 2231 11th Avenue East, 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 attendance records as required in this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 developed an IAPP for P1 that indicated P1 was susceptible to financial exploitation; however, the license holder failed to develop an IAPP for P1 that included a statement of measures that would be taken to minimize the risk of abuse to the person and other vulnerable adults when the IAPP indicated susceptibility to abuse.
· Correction Order dated July 11, 2022; and · Order of Conditional License dated October 14, 2022. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. 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. a. The license holder failed to include the following information in P1’s record: · an application form signed by the person; · a medical report, dated within the three months prior to or 30 days after the participants’ admission to the center signed by a physician, or 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 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 a medical report in P3’s record with the three months prior to or 30 calendar days after P3’s admission to the center. P3 was admitted to the center on October 2, 2023 and the license holder obtained a medical report for P3 on November 27, 2023. Repeat Violation: You were previously found in violation of this same subpart in the following orders issued by DHS: · Correction Order dated July 11, 2022; · Order of Conditional License dated October 14, 2022; and · Correction Order dated March 7, 2023. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2, item A. Violation: For one participant whose record was reviewed (P1), the license holder did not complete initial service planning as required. The license holder failed to develop a needs assessment for P1 within 30 days of the participant’s admission to the center that included P1’s physical status, determined from the medical report received from the participant’s physician. Repeat Violation: You were previously found in violation of this same subpart in the following orders issued by DHS: · Correction Order dated July 11, 2022; and · Order of Conditional License dated October 14, 2022. 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 written plans of care for P1 and P2 that included§ an update of the preliminary service plan and additional services required by the participant. Repeat Violation: You were previously found in violation of this same subpart in the following orders issued by DHS: · Correction Order dated July 11, 2022; · Order of Conditional License dated October 14, 2022; and · Correction Order dated June 26, 2023. 6. Citation: Minnesota Rules, part 9555.9720, subparts 7 and 8.
a. The license holder failed to ensure equipment and furniture was in good repair, including the following items: · a treadmill with a warped track; · broken plastic on the sides of a treadmill; and · several torn leather chairs in the quiet room. b. The license holder failed to ensure the areas used by participants were free from peeling paint, including, peeling paint on a bathroom stall and on walls throughout program spaces. c. The license holder failed to ensure rugs had nonskid backing. Repeat Violation: You were previously found in violation of this same subparts in the following orders issued by DHS: · Correction Order dated July 11, 2022; · Order of Conditional License dated October 14, 2022; and · Correction Order dated June 26, 2023. · ensure equipment and furniture is in good repair; · ensure all areas used by participants are free from loose plaster and peeling paint; and · ensure all rugs have nonskid backing. On an ongoing basis, you must maintain compliance as required in these subparts. 7. Citation: Minnesota Rules, part 9555.9730, subpart 6. Violation: The license holder did not ensure physical plant and space requirements. The license holder failed to ensure the center provided one cot, couch, or recliner per eight persons. During the licensing review on December 13, 2023, the center had twenty six participants in attendance and only two couches and one cot. Corrective Action Ordered: Immediately, you must ensure the center has one cot, couch, or recliner per eight persons in the center. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (b). Violation: The license holder did not notify the commissioner before making any change to the license holder’s controlling individuals as required. The license holder failed to notify the commissioner of the addition of controlling individuals (SP3 and SP4) that occurred on May 1, 2021. DHS requested additional information and documentation regarding this change beginning in February 2023. However, as of the licensing review on December 13, 2023, the license holder had not notified the commissioner of this change in the manner prescribed by the commissioner. Corrective Action Ordered: Within 10 days of receiving this order, you must contact your licensor to initiate and complete the request to update controlling individuals. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 me as soon as possible. Alexandra Devick, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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