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November 21, 2024 Huan Gao, Authorized Agent Sunset Care LLC 17814 Steading Road Eden Prairie, Minnesota 55347 License Number: 1085799 (Rule 223) CORRECTION ORDER Dear Huan Gao: On September 11, 2024, a licensing review of Sunset Care located at 1399 Eustis Street, 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 Rules, part 9555.9700, subpart 3. Violation: For one of three participants whose records were reviewed (P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to review P2’s IAPP quarterly as part of the review of the program plan or service plan. The license holder most recently reviewed P2’s IAPP in December 2023. b. The license holder failed to review P2’s IAPP with their interdisciplinary team, at least annually in 2023 and 2024, using the individual assessment and any reports of abuse relating to the person. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s IAPP with P2 and their interdisciplinary team. Additionally, you must document the review of P2’s IAPP in P2’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For one participant whose record was reviewed (P2), the license holder did not include information in the participant’s written record as required. The license holder failed to include a medical report, dated within the three months prior to or 30 days after P2’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician. P2 was admitted on July 1, 2022, and the license holder maintained a medical report for P2 on October 17, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P2), the license holder did not review the written plan of care as required. The license holder failed to review P2’s individual plan of care quarterly. The license holder most recently reviewed P2’s individual plan of care in December 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2’s individual plan of care. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. a. The license holder failed to maintain a contract with the food service provider. b. The license holder failed to ensure the refrigerator had a temperature of 40 degrees or less. Corrective Action Ordered: Immediately, you must ensure the refrigerator has a temperature of 40 degrees or less. Within 30 days of receiving this order, you must maintain a contract with your food service provider. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. a. The license holder failed to maintain in SP1’s personnel record: · a copy of SP1’s job description; and · documentation of an annual performance evaluation for 2023. b. The license holder failed to maintain documentation of an annual performance evaluation in SP2’s personnel record in 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP1’s personnel record; and · complete a performance evaluation for SP1 and SP2 and maintain documentation of the evaluation in SP1 and SP2’s personnel records. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 6. 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 SP1 orientation 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 within 72 hours of first providing direct contact. b. The license holder failed to provide SP1 and SP2 annual review in 2023 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 Ordered: Immediately, you must provide the required orientation and annual review detailed above to SP1 and SP2. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9555.9690, subpart 3.
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, including: · at least four hours of supervised orientation before the employee 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 Ordered: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4.
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 Statues, 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. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9720, subparts 5 and 8. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure chemicals that are poisonous when swallowed or inhaled or that are damaging to eyes or skin are be stored in an area not accessible to the participants. b. The license holder failed to ensure the areas used by participants were free from debris and litter, including: · plywood, cabinets and countertops in the upstairs hallway; and · stacked debris and litter, including boxes, curtain rods and stacked chairs and tables throughout upstairs program spaces. Corrective Action Ordered: Immediately, you must: · ensure chemicals that are poisonous when swallowed or inhaled or that are damaging to eyes or skin are stored in an area not accessible to the participants; and · ensure areas used by participants are free from debris and litter. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 10. Citation: Minnesota Rules, part 9555.9730, subpart 3. Violation: The license holder did not ensure physical plant and space requirements. The license holder failed to ensure restrooms used by participants were equipped with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance. Corrective Action Ordered: Immediately, you must equip restrooms used by participants with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not review the 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 did not have a documented review of the PAPP. 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. Compliance with this order will be reviewed onsite. 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. Kristopher Oberg, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6589
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