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January 29, 2024 Maiyer Vang, Authorized Agent Arch Adult Day Care Services LLC 11115 12th Street North Lake Elmo, Minnesota, 55042-9600 License Number: 1078913 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Maiyer Vang: On August 28, 2023 as a result of a licensing review, a Correction Order was issued to Arch Adult Day Care Services LLC located at 11115 12th Street North, Lake Elmo, Minnesota. You were ordered to take corrective action for violations determined under citations 1 through 11. On December 21, 2023, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 2, 4, 5, 6, 7, 8, 10, and 11 it was determined that corrective action has not been achieved. As a result, this Notice of Noncompliance and 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. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For four participants whose records were reviewed (P1, P2, P3 and P5), 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 that included the name and telephone number of the person to call in case of an emergency involving P1 and the name and number of another person to call if that person cannot be reached; and · a medical report, dated within the three months prior to or 30 days after P1’s admission to the center. P1’s admission date was May 1, 2023 and the license holder maintained a medical report for P1 on August 15, 2023. b. The license holder failed to include a medical report in P2’s record, dated within the three months prior to or 30 days after P2’s admission to the center. P2’s admission date was November 8, 2022 and the license holder maintained a medical report for P2 on January 6, 2023. c. The license holder failed to maintain a medical report in P3’s record that included a report on a physical examination for P3 that was updated annually in 2023. d. The license holder failed to maintain a medical report in P5’s record that included a report on a physical examination for P5 that was updated annually in 2022.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain an updated application form in P1’s record that includes the name and telephone number of the person to call in case of an emergency involving P1 and the name and number of another person to call if that person cannot be reached; and · maintain medical reports in P3 and P5’s records that include reports on the participant’s physical examination. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part.
DHS Response: The license holder failed to update P1’s application form that included the name and telephone number of the person to call in case of an emergency involving P1 and the name and number of another person to call if that person cannot be reached. Corrective Action Ordered: Within 15 days of receiving this order you must, maintain an updated application form in P1’s record that includes the name and telephone number of the person to call in case of an emergency involving P1 and the name and number of another person to call if that person cannot be reached. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. 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; and · the staff members responsible for implementing the individual plan of care.
· develop written plans of care for P1 and P2 that include the information listed 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. DHS Response: 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; and · the staff members responsible for implementing the individual plan of care. Corrective Action Ordered: Within 15 days of receiving this order, you must develop a written plan of care for P1 and P2 that includes the following; · an update of the preliminary service plan and additional services required by the participant; and · the staff members responsible for implementing the individual plan of care. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For one of five staff persons whose record was reviewed (SP3), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of an annual performance evaluation in SP3’s personnel record in 2022 and 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP3 and maintain documentation of the evaluation in SP3’s personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. DHS Response: The license holder failed to maintain documentation of an annual performance evaluation in SP3’s personnel record. Corrective Action Ordered: Within 15 days of receiving this order, you must complete a performance evaluation for SP3 and maintain documentation of the evaluation in SP3’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP2 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. Corrective Action Ordered: Immediately, you must provide the required orientation detailed above to SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. DHS Response: The license holder failed to provide SP2 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. Corrective Action Ordered: Immediately, you must provide the required orientation detailed above to SP2. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 and SP2 with 20 hours of orientation to the center within SP1 and SP2’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. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on April 27, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the required orientation training detailed above to SP1 and SP2; · complete an audit of all personnel records to ensure all staff persons have received the required orientation training detailed above; and · for staff persons that have not received the required orientation 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. DHS Response: The license holder failed to provide SP1 and SP2 with 20 hours of orientation to the center within SP1 and SP2’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. Corrective Action Ordered: Within 15 days of receiving this order, you must: · provide the required orientation training detailed above to SP1 and SP2; · complete an audit of all personnel records to ensure all staff persons have received the required orientation training detailed above; and · for staff persons that have not received the required orientation 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. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For three staff persons whose records were reviewed (SP3, SP4 and SP5), the license holder did not provide in-service training annually as required. The license holder failed to provide SP3, 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: You were cited for a similar violation in a Correction Order DHS issued on April 27, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the required in-service training detailed above to SP3, SP4 and SP5; · 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. DHS Response: The license holder failed to provide SP3, 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 9555.97430. Corrective Action Ordered: Within 15 days of receiving this order, you must: · provide the required in-service training detailed above to SP3, SP4, and SP5; · 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 in-service training, you must develop a plan detailing how your program will provide the staff person with the required training with 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Rules, part 9555.9720, subparts 1 and 2. Violation: The license holder did not ensure safety as required. a. The license holder failed to have a first aid kit that contained an ice bag or cold pack and thermometer. b. The license holder failed to post a list of emergency phone numbers, including 911, next to a telephone. Corrective Action Ordered: Immediately, you must: · ensure your first aid kit contains an ice bag or cold pack and thermometer; and · post a list of emergency phone numbers, including 911, next to a telephone. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. DHS Response: The license holder failed to have a first aid kit that contained an ice bag or cold pack and adhesive tape. Corrective Action Ordered: Immediately, you must ensure your first aid kit contains an ice bag or cold pack and adhesive tape. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). 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. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on April 27, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must review your PAPP using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. DHS Response: 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. Corrective Action Ordered: Within 15 days of receiving this order, you must review your PAPP using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 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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