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April 1, 2024 Inessa Marinov, Authorized Agent Legacy Adult Day Care 4949 Olson Memorial Highway License Number: 1054057 (Rule 223) CORRECTION ORDER Dear Inessa Marinov: On February 28, 2024, a licensing review of Legacy Adult Day Care located at 800 Boone Avenue North, Golden Valley, 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: Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9700, subpart 2, item B. Violation: For five of ten participants whose records were reviewed (P1, P2, P3, P4, and P5), the license holder did not develop a preliminary service plan as required. a. The license holder failed to develop a preliminary service plan for P1, P4, and P5 that included the role of the person’s caregiver or caregivers in carrying out the service plan. b. The license holder failed to develop a preliminary service plan for P2 that included: · the role of P2’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P2 will take part immediately upon admission. c. The license holder failed to develop a preliminary service plan for P3 that included: · transportation arrangements for getting P3 to and from the center; and · role of the person’s caregiver or caregivers in carrying out the service plan Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1, P2, P3, P4, and P5’s preliminary service plans to include the information and specifications detailed above; · complete an audit of all participants’ preliminary service plans to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 2 are maintained; and · for participants who do not have preliminary services plans that included all requirements, you must develop a plan detailing how your program will maintain a complete preliminary service plans within 60 calendar 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. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 3.
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 (PAPP), 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. SP2 provided direct contact on August 17, 2023 and was provided the required training on August 30, 2023. Corrective Action Required: Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245A.73, subdivision 1. The license holder failed to: · provide remote adult day services with two-way interactive video; and · ensure a staff person that provided remote adult day services did not provide services to more than eight participants at one time. Corrective Action Required: Immediately, you must maintain staff ratios as required. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245A.73, subdivision 2. 6. Citation: Minnesota Rules, part 9555.9690, subpart 3. The license holder failed to provide SP1 and SP2 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including training related to the kinds of functional impairments of persons currently at the center. The license holder maintained documentation that SP1 and SP2 received 18 hours of orientation within their first 40 hours of employment at the center.
7. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. The license holder failed to ensure the refrigerator located in the serving kitchen on the southeast side of the center maintained a temperature of 40 degrees or less. At the time of review, the thermometer in the refrigerator read 44 degrees. Corrective Action Ordered: Immediately, you must ensure your refrigerator maintains a temperature of 40 degrees or less. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9720, subpart 8. Violation: The license holder did not ensure safety as required. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint.
9. Citation: Minnesota Rules, part 9555.9730, subparts 3 and 7.
a. The license holder failed to ensure a minimum temperature of 70 degrees Fahrenheit was maintained in indoor areas used by people receiving services. At the time of review, the thermostat read 68 degrees Fahrenheit. b. The license holder failed to ensure restrooms used by participants were equipped with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance. Corrective Action Ordered: Immediately, you must ensure: · a minimum temperature of 70 degrees Fahrenheit is maintained in indoor areas used by people receiving services; and · all restrooms used by participants are equipped with a mechanism that participants can use to signal staff members. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts.
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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