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December 4, 2024 Brian Pattock, Authorized Agent Benedictine Adult Day Services 935 Kenwood Avenue License Number: 800181 (Rule 223) CORRECTION ORDER Dear Brian Pattock: On October 11, 2024 a licensing review of Benedictine Adult Day Services located at 935 Kenwood Avenue, Duluth, 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 9555.9700, subpart 3. Violation: For three of three participants whose records were reviewed (P1, P2, and P3), the license holder did not develop the plan of care as required. The license holder failed to develop written plans of care for P1, P2, and P3 that included the staff members responsible for implementing the individual plan of care. Corrective Action Ordered: Withing 30 days of receiving this order, you must develop written plans of care for P1, P2, and P3 that include the staff members responsible for implementing the individual plan of care. On an ongoing basis, you must maintain compliance as required in this subpart. 2. Citation: Minnesota Rules, part 9555.0030. Violation: For one participant whose record was reviewed (P1), the license holder did not meet the requirements for positive support strategies and person-centered planning 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 P1. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and implement support strategies for P1 according to the standards in part 9544.0030, subparts 2, 3, and 4. Additionally, you must: · at least every six months, evaluate with P1 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 the appropriate changes; · at least every six months, evaluate with P1 whether the services support P1’s preferences, daily needs and activities, and the accomplishment of P1’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. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose records were reviewed (SP2), the license holder did not provide annual review to a mandated reporter as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. 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. The license holder provided SP2 the required review in March 2023 and May 2024. Corrective Action Required: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9555.9690, subpart 4. 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 in-service training annually in 2024 in the following areas: · areas related to care of center participants, review of parts 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9720, subparts 2, 8 and 9.
a. The license holder failed to ensure a list of emergency phone numbers was posted next to the telephone, including 911. b. The license holder failed to ensure the areas used by participants receiving services were free from loose plaster, chipped sheetrock, and peeling paint. c. The license holder failed to ensure the emergency plans were posted in a visible place within the center. Corrective Action Ordered: Immediately, you must: · post a list of emergency numbers next to the telephone, including 911; · ensure the areas used by participants are free from loose plaster, chipped sheetrock, and peeling paint; and · post the emergency plans in a visible place within the center. On an ongoing basis, you must maintain compliance as required in these subparts. 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. Alexandra Devick, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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