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March 29, 2024 Loretta Lewis, Authorized Agent Ecumen of Litchfield Adult Day Services 200 North Holcombe Avenue Litchfield, Minnesota 55355 License Number: 1042946 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Loretta Lewis: On December 1, 2023 as a result of a licensing review, a Correction Order was issued to Ecumen of Litchfield Adult Day Services located at 200 North Holcombe Avenue, Litchfield, Minnesota. You were ordered to take corrective action for violations determined under citations 1 through 11. On February 21, 2023, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 3, 6, 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. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P1 and P2), 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: o P1’s date of admission and living arrangement; o 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; o the telephone number of P1’s physician or medical provider; · a medical report, dated within the three months prior to or 30 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 a report on a physical examination; o a medical history of P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply 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 4605.7000 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 the following in P2’s record: · a medical report for that included a physical examination for P2 that was updated annually in 2022; and · attendance and participation reports and progress notes that were recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain an updated application form and medical report in P1’s record that includes the information as detailed above; and · maintain a medical report in P2’s record that include a report on P2’s physical examination. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart.
· a medical report that included a physical examination for P2 that was updated annually; and · attendance and participation reports and progress notes that were recorded at least monthly. DHS Response: The license holder failed to maintain the following in P1’s record: · a medical report, dated within the three months prior to or 30 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 a report on a physical examination; o a medical history of P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply 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 4605.7000 to 4605.7090, that would endanger the health of other participants; and · notes on special problems, medication changes, and need for medication assistance. Corrective Action Ordered: Within 15 days of receiving this order you must, maintain a medical report for P1 that includes all information as detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P1), the license holder did not develop a written plan of care as required. The license holder failed to develop a written plan of care for P1 that included: · an update of the preliminary service plan and additional services required by the participant; · short and long term objectives for P1 stated in concrete, measurable, and time specific outcomes; and · the anticipated duration of the individual plan of care as written.
· develop a written plan of care for P1 that includes 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 a written a plan of care for P1 that included: · an update of the preliminary service plan and additional services required by the participant; and · the anticipated duration of the individual plan of care as written. Corrective Action Ordered: Within 15 days of receiving this order, you must develop a written plan of care for P1 that includes the following: · an update of the preliminary service plan and additional services required by the participant; and · the anticipated duration of the individual plan of care as written. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Rules, part 9555.9720, subpart 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure the emergency plans were posted in a visible place in the center. b. The license holder failed to include the following in the emergency plans: · identification of secondary exits; and · identification of an emergency shelter area within the center. § Corrective Action Ordered: Immediately, you must ensure the emergency plans are posted in a visible place within the center and include the information as detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. · identification of secondary exits; and · identification of an emergency shelter area within the center. Corrective Action Ordered: Immediately, you must: · ensure your emergency plans identify secondary exits and an emergency shelter area within the center; and · post your emergency plans in a visible place in the center. Within 15 days of receiving this order, you must submit your updated emergency plan to your licensor. 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. 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. 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; and · submit your PAPP and the date of the review of your PAPP to your licensor. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at alexandra.devick@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Alexandra Devick Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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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