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May 23, 2024 Brittany Bell, Authorized Agent Martin Luther Adult Day Program 7505 Metro Boulevard Suite 100 License Number: 1045460 (Rule 223) CORRECTION ORDER Dear Brittany Bell: On May 13, 2024, a licensing review of Martin Luther Adult Day Program, located at 1401 East 100th Street, Bloomington, 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 documentation of actual attendance for each adult day service recipient as detailed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two of 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 a medical report in P1’s record, 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: · indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; · a release signed by the physician indicating whether P1 may engage in a structured exercise program; and · 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. b. The license holder failed to include the following information in P2’s record: · a medical report, dated within the three months prior to or 30 days after P2’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 P2; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 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 30 days of receiving this order, you must maintain the information detailed above in P1 and P2’s participant records. · On an ongoing basis, you must maintain compliance as required in this subpart. 3. 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 participants.
4. Citation: Minnesota Rules, part 9555.0030. Violation: For one participant whose record was reviewed (P2), the license holder did not meet the requirements for positive support strategies as required. The license holder failed to incorporate positive support strategies in writing into an existing treatment, service, or other individual plan required of the license holder for P2. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and implement support strategies for P2 according to the standards in part 9544.0030, subparts 2, 3, and 4. Additionally, you must: · at least every six months, evaluate with P2 whether the identified positive support strategies currently meet the standards in subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, you must make appropriate changes; · at least every six months, evaluate with P2 whether the services support P2’s preferences, daily needs and activities, and the accomplishment of P2’s goals in accordance with Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (b), and whether the person-centered planning process compiles with Code of Federal Regulations, title 42, section 441.725, paragraph (a)(1)-(4). Based upon the results of the evaluation, you must determine whether changes are needed to enhance person-centeredness for the person, and, if so, make appropriate changes; and · maintain documentation and record keeping requirements as required in part 9544.0100. On an ongoing basis, you must maintain compliance as required in this part. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not provide orientation and annual review to a mandated reporter as required. a. The license holder failed to provide SP1 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. b. The license holder failed to provide SP1 annual review to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Corrective Action Required: Immediately, you must provide the required orientation and annual review detailed above to SP1. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least four hours of supervised orientation before SP1 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 Required: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP1), 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 the following areas: · areas related to care of center participants, including provision of medication assistance and review of parts 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1. On an ongoing basis, you must maintain compliance as required in this subpart. 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 ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 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, HCBS Human Services Licensor Licensing Division Office of Inspector General
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