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December 12, 2024 CERTIFIED MAIL Kia Yang, Authorized Agent Harmony Adult Day Center LLC 7756 Hemingway Avenue South Cottage Grove, Minnesota 55016 License Number: 1104184 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Kia Yang: The Department of Human Services (DHS) is placing your license to provide adult day care services at Harmony Adult Day Center LLC, located at 475 Etna Street, St. Paul, Minnesota on conditional status for two years, beginning December 12, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On November 21, 2024 and November 25, 2024, a DHS licensor conducted a licensing review at your facility located at 475 Etna Street, St. Paul, Minnesota. As a result of these licensing visits, DHS determined that your program failed to comply with the laws and rules that apply to licensed adult day centers, citing 11 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to provide orientation to reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan; o Failure to develop and review individual abuse prevention plans; o Failure to distribute policies and program information; o Failure to maintain and meet the requirements for attendance record documentation; o Failure to maintain participant records; o Failure to complete initial service planning and develop written plans of care; o Failure to ensure safety; o Failure to offer services; and o Failure to post a copy of the internal and external reporting policies and procedures related to suspected or alleged maltreatment of vulnerable adults. · Chronicity: Your program received its license on March 2, 2020. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o August 22, 2022 Correction Order: 12 Violations o September 19, 2022 Order to Pay a Fine 1 Background Study Violation o November 14, 2022 Correction Order: 4 Violations o December 12, 2024 Conditional License (this order): 11 Violations (4 repeat) · Severity: At a licensing review conducted on November 21, 2024, a DHS licensor conducted an exit interview where they outlined your non-compliance with licensing rules and statutes determined at the review. Due to your failure to maintain participant records and emergency phone numbers for participants, DHS licensors instructed you to maintain emergency phone numbers for current participants prior to continuing services. On November 25, 2024, a follow-up licensing review was conducted to determine the license holder maintained emergency phone numbers of each participants’ caregiver and primary physician. Although the license holder maintained emergency phone numbers as required, DHS has concerns that without continuous oversight of your program, the health and safety of the vulnerable adults served by the program would be at risk. DHS must rely on license holders to demonstrate competent knowledge of the applicable requirements of rules and statutes as DHS is unable to provide continuous oversight of license holders and programs. Due to your program’s history of noncompliance, DHS has no assurance you can be trusted with the well-being of vulnerable persons served by the program in the absence of constant supervision. Many of the violations that led to the Order of Conditional license relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status. Licensing Violations Determined on November 21 and 25, 2024 DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For three of three participants whose records were reviewed (P1-P3), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan (PAPP) as required. The license holder failed to provide orientation to P1-P3 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). Corrective Action Ordered: Immediately, you must: · provide an orientation to P1-P3 on your internal and external reporting procedures and PAPP; and · document that P1-P3 were provided orientation in P1-P3’s records. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop IAPPs for P1-P3 as part of the participant’s initial individual program plan or service plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Corrective Action Ordered: Immediately, you must develop IAPPs for P1-P3. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required. a. The license holder failed to distribute the following policies and program information to P1-P3 and the participants’ caregivers upon admission: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. b. The license holder failed to distribute the participants' rights to P1- P3 upon admission. Rule Violated: Minnesota Rules, part 9555.9640. Corrective Action Ordered: Immediately, you must: · distribute the policies, program information, and participants’ rights listed above to P1-P3, and their caregivers; and · document the distribution of the policies, program information, and participants’ rights in P1-P3’s records. On an ongoing basis, you must maintain compliance as required in this rule. 4. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not include information in the participant’s written record as required. a. The license holder failed to include the following information in P1-P3’s record: · an application form signed by the participant or participant’s caregiver that included: o the participant’s name, address, date of birth, sex, date of admission readmission, living arrangement, telephone number, and source of referral; o the name and telephone number of the person to call in case of an emergency involving the participant and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of the participants’ physician or medical provider; · a medical report dated within the three months prior to or 30 days after the participant’s admission to the center, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that included: o a report on a physical examination; o a medical history of the participant; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to the participant; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that the participant is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants; · the person’s service agreement with the center, that specified the responsibilities of the person and the center with respect to payment for and provision of services and signed by the person or the person’s caregiver and the center director; · participation reports and progress notes that were recorded at least monthly; · notes on special problems, medication changes, and need for medication assistance; and · a statement signed by the center director and person at the time of admission specifying the basis on which the person was determined to be capable or incapable of taking appropriate action for self-preservation under emergency conditions. b. The license holder failed to provide P1-P3 with written notice that ensured the participant or their guardians had been informed of the participant’s right to contest the accuracy and completeness of the data maintained in the record. Rule Violated: Minnesota Rules, part 9555.9660, subparts 1 and 3. Repeat Violation: In a Correction Order that DHS issued on November 14, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1-P3’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 5. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not complete initial service planning as required. a. The license holder failed to conduct needs assessments for P1-P3 within 30 days of admission that addressed: · the participant’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · the participant’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · the participant’s physical status, to be determined by observation, from the intake screening interview, and from the medical report received from the participant’s physician. b. The license holder failed to develop preliminary service plans for P1-P3 within 30 days of admission that included: · scheduled days of the participant’s attendance at the center; · transportation arrangements for getting the participant to and from the center; · the participant’s nutritional needs and, where applicable, dietary restrictions; · role of the participant’s caregiver or caregivers in carrying out the service plan; and · services and activities in which the participant would take part immediately upon admission. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on November 14, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1-P3 as detailed above; · develop preliminary service plans for P1-P3 that include the information and specifications detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 6. 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 written plans of care for P1-P3 that included: · an update of the preliminary service plan and additional services required by the participant; · short and long term objectives for the participant stated in concrete, measurable, and time specific outcomes; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on November 14, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must develop written plans of care for P1-P3 that include the information listed above. On an ongoing basis, you must maintain compliance as required in this subpart. SERVICE AND PROGRAM VIOLATIONS 7. 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. Statute Violated: Minnesota Statutes, section 245A.14, subdivision 14, paragraph (c). Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Violation: The license holder did not offer services as required. a. The license holder had food prepared off-site but failed to maintain a current and accurate contract with the food service provider.
b. The license holder failed to maintain family and social histories for P1 and P2 that were updated annually. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1 and 7. Corrective Action Ordered: During a follow up review conducted on November 25, 2024, the license holder maintained a current contract with their food service provider. Within 30 days of receiving this order, you must maintain family and social histories in P1 and P2’s records. On an ongoing basis, you must maintain compliance as required in these subparts. SAFETY VIOLATIONS 9. Violation: The license holder did not maintain emergency phone numbers for participants as required. The license holder failed to have the following information for P1-P3 readily available at the center: · the emergency phone numbers of caregivers; · the person to be called if the caregiver cannot be reached; and · the participant’s physician. Rule Violated: Minnesota Rules, part 9555.9720, subpart 3. Corrective Action Required: During a licensing review conducted on November 25, 2024, the license holder maintained the information detailed above in P1-P3’s records. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Violation: The license holder did not ensure safety as required. The license holder failed to store chemicals that were poisonous when swallowed or inhaled or that were damaging to eyes or skin in an area not accessible to the participants. Chemicals were stored on the floor of the women’s restroom. Rule Violated: Minnesota Rules 9555.9720, subpart 5. 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. On an ongoing basis, you must maintain compliance as required in this subpart. POLICY AND PROCEDURE VIOLATIONS 11. Violation: The license holder did not post a copy of the internal and external reporting policies and procedures as required.
The license holder failed to post a copy of the internal and external reporting policies and procedures in a prominent location in the center. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Repeat Violation: In a Correction Order that DHS issued on November 14, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Immediately, you must post a copy of the internal and external reporting policies and procedures in a prominent location in the program. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 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 15 days of receiving this order, you must: · develop a quality assurance audit tool to ensure personnel records include all required documentation and training; and · develop a quality assurance audit tool to ensure participant records include all required information. 3. Within 30 days of developing your quality assurance audit tools, you must: · complete an audit of all participant and personnel records using the approved quality assurance audit tool; · submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. The date that all participant and personnel records will be brought into compliance must be no later than within 90 days of receiving this order; and · maintain the results of the audit at your center in a manner that is accessible to the commissioner for review. 4. During the first six (6) months of your conditional license and until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards, no new admissions will be allowed. During the duration of the conditional license, you must notify your licensor and receive approval prior to admitting new participants to your program. The notification to your licensor must include the name of the participant, the participant’s anticipated date of admission, documentation of compliance with term 1 of your conditional license, and your plan to meet compliance with individual service planning requirements. 5. You may not increase the hours or days of operation of you program or increase the capacity of your program for the duration of the conditional license. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Desiree.B.Tiller@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Desiree Tiller 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 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 Desiree Tiller, HCBS Licensor, at 651-431-4622. Sincerely, Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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