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January 21, 2025
Sudi Egal, Authorized Agent Adult Care LLC 1229 East Lake Street Suite 200 Minneapolis, Minnesota 55407 License Number: 1097508 (Rule 223) CORRECTION ORDER Dear Sudi Egal: On November 6, 2024, a licensing review of Adult Care LLC, located at 1229 East Lake Street, Minneapolis, 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 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 documentation of actual attendance for each adult day service recipient. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For four of four participants whose records were reviewed (P1, P2, P3, and P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P1 that included an individualized assessment of P1’s susceptibility to abuse, including self-abuse. The license holder maintained documentation that P1 was not capable of self preservation; however, the license holder developed an IAPP for P1 that documented that P1 was not at risk for abuse. b. The license holder failed to review P1-P4’s IAPPs quarterly as part of the review of the program plan or service plan. Repeat Violation: In a Correction Order that DHS issued on May 9, 2022, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1 that includes an individualized assessment of P1’s susceptibility to abuse by other individuals; · review P1, P2, P3, and P4’s IAPPs with the participant’s interdisciplinary teams and document the review; · complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and · for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P3, and P4), 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’s record: · an application form that included P1’s telephone number; · a medical report, dated within the three months prior to or 30 days after P1’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, updated annually; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · notes on special problems or on changes needed in medication and on the need for medication assistance. b. The license holder failed to include the following information in P3’s record: · an application form that included P3’s source of referral; · the name and telephone number of the person to call in case of emergency involving the person and name and number of another person to call if that person cannot be reached; · a medical report, dated within the three months prior to or 30 days after P3’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician; · notes on special problems or on changes needed in medication and on the need for medication assistance; and · a statement signed by the center director and P3 at the time of P3’s admission specifying the basis on which P3 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. c. The license holder failed to include the following information in P4’s record: · an application form that included P4’s source of referral; · a medical report, dated within the three months prior to or 30 days after P4’s admission to the center signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician; and · notes on special problems or on changes needed in medication and on the need for medication assistance. Repeat Violation: In a Correction Order that DHS issued on May 9, 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, and P4’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P3, and P4), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P1, P3, and P4 that included the participants’ physical status from the medical reports received from P1, P3, and P4’s physicians. Repeat Violation: In a Correction Order that DHS issued on May 9, 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 needs assessments to include the participant’s physical status based on the information received from the participant’s medical report. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3.
The license holder failed to develop a written plan of care for P1-P4 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; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Repeat Violation: In a Correction Order that DHS issued on May 9, 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-P4 to include the information detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For three of three staff persons and two consultants whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain personnel files as required. a. The license holder failed to maintain a job description in SP1 and SP2’s personnel records. b. The license holder failed to maintain documentation of an annual performance evaluation in SP2’s personnel record in 2024. c. The license holder failed to maintain a personnel file for the registered dietician that included: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the registered dietician meets any licensure, registration, or certification requirements required to perform the services specified in the contract. d. The license holder failed to maintain a personnel file for the registered nurse that included documentation that the registered nurse meets any licensure, registration, or certification requirements required to perform the services specified in the contract. Repeat Violation: In a Correction Order that DHS issued on May 9, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain documentation of SP1, SP2, and SP3’s job descriptions in their personnel records; · complete a performance evaluation for SP2 and maintain documentation of the evaluation in SP2’s personnel record; · maintain a personnel file for the registered dietician that includes: o a copy of a signed contract or letter or appointment specifying conditions and terms of employment; and o documentation that the registered dietician meets any licensure, registration, or certification requirement required to perform the services specified in the contract; · maintain a personnel file for the registered nurse that includes documentation that the registered nurse meets any licensure, registration, or certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these items. 7. 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 a minimum of eight hours of in-service training annually in areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730 in 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP2. 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 9555.9710, subpart 7. Violation: The license holder did not offer services as required. The license holder failed to maintain family and social histories for P1 and P2 that were updated annually. Repeat Violation: In a Correction Order that DHS issued on May 9, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order: you must maintain and update P1 and P2’s family and social history, as applicable. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9720, subparts 1, 7, and 8. Violation: The license holder did not ensure safety as required. a. The license holder failed to have a first aid kit that contained a thermometer. b. The license holder failed to ensure equipment and furniture was in good repair; including a broken treadmill. c. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint including: · exposed plaster; · chipped and peeling paint; · damaged ceiling tiles; and · carpet squares not secured to the floor. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure your first aid kit contains a thermometer; · ensure equipment is in good repair; and · ensure the areas used by participants are free from loose plaster and peeling paint. 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 establish a program abuse prevention plan (PAPP) as required.
a. The license holder failed to review the PAPP at least annually. b. On November 6, 2024, DHS licensors observed the following at the license holder’s center: · participants on the second floor utilizing walkers and canes for ambulation; and · active illegal drug use directly outside the entrance of the adult day center. Although these are ongoing concerns, the license holder failed to include an assessment of the physical plant, including the condition and design of the building as it relates to the safety of the clients and an assessment of the environment for the center, including the location of the program in a particular neighborhood, within their PAPP. Corrective Action Ordered: Immediately, you must review your PAPP using the assessment factors in the plan and ensure an accurate assessment of the physical plant and environment for your facility, including the condition and design of the building and location of your program in a particular neighborhood, is included in your PAPP. Within 30 days of receiving this order, you must review your PAPP. 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. Katie Johnson, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4113
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