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December 31, 2024 Kulcharee Lor, Authorized Agent Starfish Center 1072 Payne Avenue License Number: 1103243 (Rule 223) CORRECTION ORDER Dear Kulcharee Lor: On September 11, 2024, a licensing review of Starfish Center located at 1072 Payne Avenue, 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.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 attendance records as required in this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one of four 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 include measures including specific actions the program would take to minimize the risk of financial exploitation within the scope of the services in the IAPP for P1. Corrective Action Ordered: Within 30 days of receiving this order, you must include measures and specific actions the program will take to minimize the risk of financial exploitation in P1’s IAPP. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P1 and P3), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P1 and P3 that addressed the participant’s physical status determined from the medical reports received from the participant’s physician. Repeat Violation: In a Correction Order that DHS issued on January 11, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1 and P3’s needs assessments to include an assessment of their physical status determined from the medical reports received from the participant’s physician. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, P3, and P4), 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, and P4 that included short and long term objectives stated in concrete, measurable, and time specific outcomes. Repeat Violation: In a Correction Order that DHS issued on January 11, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1, P3, and P4’s written plans of care to include short and long term objectives stated in concrete, measurable, and time specific outcomes. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9720, subpart 8. Violation: The license holder did not meet safety requirements. The license holder failed to ensure rugs had nonskid backing. Repeat Violation: In a Correction Order that DHS issued on January 11, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Immediately, you must ensure rugs have nonskid backing. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9730, subpart 4. Violation: The license holder did not ensure physical plant and space requirements. At the time of the licensing review, DHS licensors observed 28 participants attending the center and multiple people arrive at the center at 9:00 am and the authorized agent stated these were community members that were receiving unlicensed services. As a result of providing unlicensed services to individuals, the common space that the individuals occupied was considered multifunctional and was not allowed to be usable space; therefore, at the time of the licensing review, the license holder’s capacity was limited to 15 adults. The license holder failed to ensure the required space available for use by participants was maintained while the center was operating. Corrective Action Ordered: Immediately, you must: · not provide other services, other than adult day care, in your adult day center that create a multifunctional organization during your licensed days and hours of operation; or · if sharing common space with a multifunctional organization, ensure the required space available for use by participants is maintained while the center is operating. Usable indoor space must not count any space occupied by persons associated with the multifunctional organization while participants are using common space. On an ongoing basis, you must maintain compliance as required in this subpart. 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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