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July 10, 2024 Laura Borris, Authorized Agent Sacred Heart Adult Day Care 1200 12th Street Southwest Austin, Minnesota 55912-2619 License Number: 802174 (Rule 223) CORRECTION ORDER Dear Laura Borris: On June 12, 2024, a licensing review of Sacred Heart Adult Day Care located at 1200 12th Street Southwest, Austin, 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For one of two participants whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop an IAPP for P1 as part of the initial individual program plan or service plan prior to or upon service initiation. Additionally, the license holder failed to review P1’s IAPP quarterly as part of the review of the program plan or service plan. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision and subpart. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not maintain a written record as required. The license holder failed to include the following information in P1 and P2’s records: · a medical report, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician; and · participation reports and progress notes that were recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P1 and P2’s participant record. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P2), the license holder did not develop a written plan of care as required. The license holder failed to develop a written plan of care for P2 that included provisions for quarterly review and quarterly revisions of the individual plan of care. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s individual plan of care and revise the plan based on the results of the review. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9710, subpart 1.
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. 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. On an ongoing basis, you must maintain compliance as required in these subparts. 6. 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. 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. 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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