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October 10, 2024 CERTIFIED MAIL Neda Chang, Authorized Agent Twin Cities Adult Day Services LLC 5209 Suntide Pass License Number: 1076130 (Rule 223) ORDER OF A CONDITIONAL LICENSE (EXTENDING AN EXISTING CONDITIONAL LICENSE FOR ONE YEAR) Dear Neda Chang: The Department of Human Services (DHS) is extending your license to provide adult day care at Twin Cities Adult Day Services LLC, 2231 11th Avenue East, North Saint Paul, Minnesota on conditional status for one year, beginning October 14, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day services licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE · October 14, 2024 Order of Conditional License (this order): 8 Violations (5 repeat) · May 23, 2024 Correction Order: 8 Violations (3 repeat) · January 26, 2024 Correction Order: 8 Violations (5 repeat) · June 26, 2023 Correction Order: 4 Violations · March 7, 2023 Correction Order: 4 Violations (4 repeat) · October 14, 2022 Order of Conditional License: 10 Violations (9 repeat) As a result of your noncompliance with licensing requirements and your failure to comply with the terms of the October 14, 2022, Order of Conditional License, DHS is issuing a new Order of Conditional License to extend the existing conditional license for one year or until October 13, 2025. On August 29, 2024, DHS determined that you failed to follow one of four terms of the Order of Conditional License that was in place from October 14, 2022 to October 13, 2024. Term #1: You were ordered to notify new persons receiving services, referral sources, and payor sources that the license was on conditional status before they began receiving adult day services. The notification was to include the following information: · specify the length of time of the conditional status of the license; · the reasons the license was made conditional; and · it must include either of a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. At the time of review, DHS licensors asked the license holder if the notice was being provided in accordance with the terms of the Order of Conditional License. The license holder informed DHS licensors they were not providing notification to new persons receiving services, referral sources, and payor sources as ordered in Term #1. Licensing Violations On August 29, 2024, DHS licensors conducted a licensing review to determine whether compliance with the Terms of the Conditional License had been met. As a result of these review, DHS determined the following violations. PARTICIPANT RECORD VIOLATIONS 1. Violation: For one of three participants whose records were reviewed (P3), the license holder did not include information in the participant’s written record as required. The license holder failed to maintain a medical report in P3’s record that included a physical examination, updated annually. The most recent report on a physical examination that the license holder maintained for P3 was dated June 2, 2023. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not develop a written plan of care as required. a. The license holder failed to develop a written plan of care for P1 that included the following: · an update of the preliminary service plan and additional services required by the person; and · short and long term objectives for the person stated in concrete, measurable, and time specific outcomes. b. The license holder failed to develop a written plan of care for P2 that included an update of the preliminary service plan and additional services required by the person. c. The license holder failed to develop a written plan of care for P3 that included provisions for quarterly review and quarterly revisions of the individual plan of care. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3.
3. Violation: The license holder did not ensure staff coverage of the center as required. The license holder failed to have a person certified in cardiopulmonary resuscitation and the treatment of obstructed airways present at all times: · in the center when participants were present; · in a vehicle being used by the center to transport participants; and · with participants on field trips or other activities conducted by the center away the center site. Rule Violated: Minnesota Rules, part 9555.9690, subpart 2. 4. Violation: For one of four staff persons whose records were 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. Rule Violated: Minnesota Rules, part 9555.9690, subpart 3. Repeat Violation: In a Correction Order that DHS issued on May 23, 2024, you were previously found in violation of this same rule. 5. Violation: For two staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide in-service training annually as required.
SERVICE AND PROGRAM VIOLATIONS 6. Violation: The license holder did not offer services as required. The license holder failed to maintain a monthly plan for diversified daily program activities that included: · socialization activities, such as group projects and recreational activities; · cultivation of personal interests, such as arts, crafts, and music; and · activities designed to increase the participant’s knowledge and awareness of the environment and to enhance language and conceptual skills.
Corrective Action Ordered: Immediately, you must maintain a monthly plan for diversified daily program activities as detailed above and enforce the plan. On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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.
Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a. SAFETY VIOLATIONS 8. Violation: The license holder did not ensure safety as required. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint. Rule Violated: Minnesota Rules, part 9555.9720, subpart 8. 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 extended 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: · submit a new center director, other than SP3, to your licensor; · submit a copy of the new center director’s resume detailing how they meet the center director qualifications according to Minnesota Rules, part 9555.9680, subpart 1; and · submit a copy of their signed job description that indicates the license holder’s responsibility ensuring the center director meets all of the responsibilities and duties of this role. 3. Within 60 days of receiving this order, you must complete an audit of all participant and personnel records using the self-monitoring checklists and use the DHS sample forms available on the Department of Human Services website (https://mn.gov/dhs/partners-and-providers/licensing/adult-day-care/) to bring records into compliance. All participant and personnel records must be brought into compliance within 90 days of receiving this order. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Alexandra.Devick@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Alexandra Devick 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 9550.9600 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 Alexandra Devick, HCBS Licensor, at 651-431-4626. Sincerely,
Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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