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May 23, 2024 Neda Chang, Authorized Agent Twin Cities Adult Day Services LLC 5209 Suntide Pass Woodbury, Minnesota 55129-1605 License Number: 1076130 (Rule 223) CORRECTION ORDER Dear Neda Chang: On April 26, 2024, 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.65, subdivision 2, paragraph (b) and Minnesota Statutes, section 626.557, subdivision 14, paragraph (b). Violation: For three of three participants whose records were reviewed (P1, P2 and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P1 and P2 that contained an individualized assessment. The license holder developed IAPPs for P1 and P2 that included measures to minimize the risks for financial exploitation that were identical. b. The license holder failed to document the review of P3’s IAPP at least annually with P3’s interdisciplinary team, using the individual assessment and any reports of abuse relating to the person, and revise the plan to reflect the results of this review. Repeat Violation: In a Correction Order that DHS issued on January 26, 2024, you were previously found in violation of this same statute.
· update P1 and P2’s IAPPs to include an individualized assessment as detailed above; and · review P3’s IAPP with P3’s interdisciplinary team, document the review, and revise the plan to reflect the results of the review. 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 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 a medical report in P1’s record, 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. b. The license holder failed to include a medical report in P3’s record that included a physical examination that was updated annually in 2024. The license holder maintained a medical report dated March 10, 2023. Repeat Violation: In a Correction Order that DHS issued on January 26, 2024, you were previously found in violation of this same rule. 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 participant. Repeat Violation: In a Correction Order that DHS issued on January 26, 2024, you were previously found in violation of this same rule. 4. Citation: Minnesota Rules, part 9555.9650, item A. Corrective Action: Within 30 days of receiving this order, you must maintain a job description in SP3’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 5. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For two staff persons whose records were reviewed (SP1 and SP4), the license holder did not provide orientation to the center as required.
The license holder failed to provide SP1 and SP4 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP2 a minimum of eight hours of in-service training annually in 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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. The license holder most recently reviewed their PAPP on March 17, 2023. 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245A.04, subdivision 7a. Violation: The license holder did not notify the commissioner and obtain the commissioner’s approval before making any changes that would alter the license information, including the hours of operation, as required.
Corrective Action Ordered: Immediately, you must comply with the special conditions stated on your license, including the hours of operation. 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, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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