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June 3, 2024 CERTIFIED MAIL Stuart Lindeman, Authorized Agent Mission Today 302 Knights Run Avenue Suite 900 Tampa, Florida 33602 License Number: 1073846 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Stuart Lindeman: The Department of Human Services (DHS) is placing your license to provide adult day care at Mission Today, 5430 Boone Ave North, New Hope, Minnesota on conditional status for two years, beginning June 3, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On November 9, 2023, DHS licensors conducted a licensing review at your facility located at 5430 Boone Avenue North, New Hope, Minnesota. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed adult day centers. As a result of that licensing review, an amended correction order was issued, dated January 9, 2024, citing 11 violations. On May 2, 2024, a follow-up licensing review was made to your facility. DHS determined that you had not complied with the corrective action ordered in the amended correction order dated January 9, 2024. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to provide orientation to reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan; o Failure to develop and review individual abuse prevention plans; o Failure to distribute policies and program information; o Failure to maintain participants’ written records; o Failure to complete initial service planning; o Failure to maintain personnel records; o Failure to provide required annual training to staff persons o Failure to ensure safety; and o Failure to offer services. · Chronicity: Your program received its license in January, 2015. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o May 8, 2017 Correction Order: 7 violations o April 3, 2019 Correction Order: 7 violations (2 repeat) o January 9, 2024 Amended Correction Order: 11 violations (4 repeat) o June 3, 2024 Conditional License (this order): 9 violations (9 repeat) · Severity: Many of the violations that led to the Order of Conditional license relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop IAPPs for P1 and P2 as part of their initial individual program plan or service plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same statute. 2. Violation: For one participant whose record was reviewed (P2), the license holder did not complete initial service planning as required. The license holder failed to develop a preliminary service plan for P2 that included: · scheduled days of P2’s attendance at the center; and · the role of P2’s caregiver or caregivers in carrying out the service plan. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. 3. Violation: For one participant whose record was reviewed (P1), the license holder did not complete initial service planning as required. The license holder failed to develop the individual plan of care for P1 that included: · an update of the preliminary service plan required in subpart 2 and additional services required by the participant; · short and long-term objectives for the participant stated in concrete, measurable, and time specific outcomes; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; and · provisions for quarterly review and quarterly revision of the individual plan of care. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. PERSONNEL RECORD & CENTER COVERAGE VIOLATIONS 4. Violation: For one of two staff persons (SP2) and the consultants whose records were reviewed, the license holder did not maintain personnel files as required. a. The license holder failed to maintain documentation of annual performance evaluations in SP2’s personnel record. b. The license holder failed to maintain a personnel file for each consultant, including the registered dietician, registered nurse, and registered physical therapist, that included: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the person under contract met any licensure, registration, or certification requirements required to perform the services specified in the contract. Rule Violated: Minnesota Rules, part 9555.9650, items A and B. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. 5. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide annual review to a mandated reporter as required. The license holder failed to provide SP2 annual review 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same statute. 6. 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 areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730. Rule Violated: Minnesota Rules, part 9555.9690, subpart 4. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. SERVICE AND PROGRAM VIOLATIONS 7. Violation: The license holder did not offer services as required. a. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietician and met all applicable state rules and laws and United States Department of Agriculture regulation. b. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly, that included: · monitoring a person’s health status and reporting changes to the person’s caregiver, physician, and center director; · educating and counseling persons on good health practices; · maintaining a listing of professional health resources available for referrals as needed by people; · developing policies and monitoring procedures for participant self-administration of medications for training unlicensed personnel who provide medication assistance; and; · supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 2, item C. c. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1, 3, and 4. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. 8. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure the areas used by participants were free from peeling paint. b. The license holder failed to post the plans for emergencies caused by fire, blizzard, and tornadoes in a visible place in the center. c. The license holder failed to have written procedures governing medical emergencies. Rule Violated: Minnesota Rules, part 9555.9720, subparts 8, 9, and 10. Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same rule. 9. 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 documented a review of the PAPP in March 2019. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on January 9, 2024, you were previously found in violation of this same statute. Corrective action required You must correct the violations as described above. If you fail to demonstrate substantial compliance with adult day care requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the adult day care licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving adult day care services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. Additionally, while the license is on conditional status, you must maintain documentation of the names of individuals you’ve provided the notification to and the date the individual was provided the notification. 2. Within 30 days of receiving this order, you must: · develop a quality assurance audit tool to ensure personnel records include all required documentation and training; · develop a quality assurance audit tool to ensure participant records include all required information; and · submit the quality assurance audit tools to your DHS licensor for approval. 3. Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you must complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you must submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 4. During the first 30 days of your conditional license, no new admissions will be allowed. After this time, you must notify your licensor and receive approval prior to admitting new participants to your program. The notification to your licensor must include the name of the participant, the participant’s anticipated date of admission, documentation of compliance with term 1 of your conditional license, and your plan to meet compliance with individual service planning requirements. New participants approved by DHS will be limited to no more than 10 in the first six months of your conditional license. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Katie.Johnson@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Katie Johnson YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all adult day care laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Adult day care centers are required to follow Minnesota Statutes, chapters 245A and 245C and Minnesota Rules, parts 9555.9600 to 9555.9730. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, HCBS Unit Supervisor, at 651-431-6591. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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