|
June 11, 2024 Brittany Bell, Authorized Agent Ebenezer Ridges Adult Day Center 7505 Metro Boulevard Suite 100 License Number: 800712 (Rule 223) CORRECTION ORDER Dear Brittany Bell: On June 3, 2024, a licensing review of Ebenezer Ridges Adult Day Center located at 13810 Community Drive, Burnsville, 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 Rules, part 9555.9660, subpart 1. Violation: For one of three participants whose record was reviewed (P1), the license holder did not include information in the participant’s written record as required. The license holder failed to include an application form that included P1’s source of referral in P1’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s application form to include P1’s source of referral. On an ongoing basis, you must maintain compliance as required in this subpart. 2. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P3), 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 P3 that included an update of the preliminary service plan and additional services required by the participants.
3. 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. 4. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2) and two consultants whose records were reviewed, the license holder did not maintain a personnel record as required. a. The license holder failed to maintain documentation of annual performance evaluation in SP1 and SP2’s personnel records in 2024. b. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment for the physical therapist and registered nurse. Corrective Action Ordered: Within 30 days, you must: · maintain documentation of annual performance evaluations for SP1 and SP2 in their personnel records; and · maintain a copy of a signed contract or letter of appointment with your registered nurse and your physical therapist specifying conditions and terms of employment. On an ongoing basis, you must maintain compliance as required in these items. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation and annual review to a mandated reporter as required. a. 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. b. The license holder failed to provide SP1 and 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 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 and SP2. 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 (SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP2 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 SP2 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 SP2. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 and SP2 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 and SP2. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9710, subparts 1 and 4.
a. The license holder failed to ensure 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 regulations. b. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly in 2023. Corrective Action Required: Within 30 days of receiving this order, you must: · ensure your menus for all meals and snacks have been approved by a registered dietician; and · have your physical therapist develop and provide consultation and review of your exercise program. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Rules, part 9555.9720, subpart 7. Violation: The license holder did not ensure safety as required. Corrective Action: Immediately, you must ensure equipment and furniture is in good repair. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a), part (2). Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. The license holder failed to identify the secondary person or position to whom internal reports may be made and the secondary person or position responsible for forwarding the internal report to the common entry point. Corrective Action Ordered: Immediately, you must update your written policies and procedures related to suspected or alleged maltreatment of vulnerable adults with the information as detailed above. 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 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
|
