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February 10, 2025
May Yang, Authorized Agent Southview Adult Day Center 835 Southview Boulevard South St. Paul, Minnesota 55075 License Number: 1100438 (Rule 223) CORRECTION ORDER Dear May Yang: On December 9, 2024, a licensing review of Southview Adult Day Center, located at 835 Southview Boulevard, South St. 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). On December 13, 2024, a follow-up licensing review was conducted. As a result of these licensing reviews 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 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 1, paragraph (c), and subdivision 2, paragraph (a). Violation: For three of three participants whose records were reviewed (P1, P2, and 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, P2, and P3 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. Corrective Action Required: Immediately, you must: · provide an orientation to P1, P2, and P3 on your internal and external reporting procedures and PAPP; and · document that P1, P2, and P3 were provided orientation in P1, P2, and P3’s records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two participants whose records were reviewed (P1 and 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 and P3 as part of the participant’s initial individual program plan or service plan. Corrective Action Ordered: Immediately, you must develop IAPPs for P1 and P3. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and 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’s record: · an application form that included: o P1’s date of admission and source of referral; and o the telephone number of P1’s physician; · participation reports and progress notes that are recorded at least monthly. b. The license holder failed to include the following information in P2’s record: · an application form that included: o P2’s name, address, date of birth, sex, date of admission, living arrangement, telephone number and source of referral; o the name and telephone number of the person to call in case of emergency involving P2 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P2’s physician or medical provider; · 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 that included: o a report on a physical examination, updated annually; o P2’s medical history; o indication of dietary restriction and medication regimen, including the need for medication assistance that apply to P2; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and · documentation that P2 was free from communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · participation reports and progress notes that are recorded at least monthly. c. The license holder failed to include the following information in P3’s record: · an application form that included: o P3’s date of admission, living arrangement, telephone number, and source of referral; o the name and telephone number of the person to call in case of emergency involving P3 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P3’s physician or medical provider; · 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, that included: o a report on a physical examination, updated annually; o P3’s medical history; o indication of dietary restriction and medication regimen, including the need for medication assistance that apply to P3; o a release signed by the physician indicating whether P3 may engage in a structured exercise program; and o documentation that P3 was free from communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · participation reports and progress notes that are recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2, and P3’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. 5. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder failed to conduct needs assessments for P1 and P2 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 a preliminary service plan for P1 within 30 days of admission that included: · role of P1’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P1 would take part immediately upon admission. c. The license holder failed to develop a preliminary service plan for P2 and 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. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1 and P2 as detailed above; and · develop preliminary service plans for P1, P2, and P3 that include the information and specifications 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 (SP1, SP2, and SP3) and three consultant whose records were reviewed, the license holder did not maintain personnel files as required. a. The license holder failed to maintain a job description in SP1, SP2 and SP3’s personnel records. b. 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. c. The license holder failed to maintain a personnel file for the physical therapist and registered dietician that included: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the physical therapist meets any licensure, registration, or certification requirements required to perform the services specified in the contract. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain job descriptions in SP1, SP2, and SP3’s personnel records; · maintain documentation that your registered nurse, physical therapist, and registered dietician meet any licensure, registration, or certification requirements required to perform the services specified in the contract; and · maintain a copy of a signed contract or letter of appointment with your physical therapist and registered dietician specifying conditions and terms of employment. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these items. 7. Citation: Minnesota Rules, part 9555.9690, subpart 2. Violation: The license holder did not ensure staff coverage of the center as required.
The license holder failed to have a person certified in cardiopulmonary resuscitation (CPR) and the treatment of obstructed airways present at all times in the center when participants were present.
Corrective Action Ordered: Immediately, you must ensure a staff person certified in cardiopulmonary resuscitation and the treatment of obstructed airways is present at all times. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation to the center as required.
The license holder failed to provide SP1, SP2, and SP3 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 working directly with persons at the center; · training related to the kinds of 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 SP1, SP2, and SP3 with the required orientation training detailed above. 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 Statutes, section 245A.65, subdivision 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did provide orientation to a mandated reporter as required. The license holder failed to provide SP1, SP2, and SP3 orientation 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, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving service within 72 hours of first providing direct contact. Corrective Action Ordered: Immediately, you must provide SP1, SP2, and SP3 with the orientation to the reporting requirements detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3 and 4. Violation: The license holder did not offer services as required. a. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietician. b. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly, that included: · monitoring a person’s health status and reporting changes to the person’s caregiver, physician, and center director; · educating and counseling persons on good health practices; · maintaining a listing of professional health resources available for referrals as needed by people; · developing policies and monitoring procedures for participant self-administration of medications for training unlicensed personnel who provide medication assistance; and; · supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 2, item C. c. The license holder failed to offer a daily structured exercise program that was developed in consultation with a registered physical therapist. Additionally, the license holder failed to ensure the registered physical therapist provided consultation and review of the exercise program, at least quarterly. Corrective Action Ordered: Within 30 days of receiving this order, you must provide services as stated above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 11. Citation: Minnesota Rules, part 9555.9720, subparts 1, 3, and 7.
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 have the emergency phone numbers of the caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician for each participant were readily available at the center. d. The license holder failed to ensure equipment and furniture was in good repair, including broken massage chairs and damaged ceiling tiles. Corrective Action Ordered: Immediately, you must: · ensure your first aid kit contains a thermometer; · ensure emergency phone numbers of the caregiver, the persons to be called if the caregiver cannot be reached, and the participant’s physician for each participant are readily available at the center; and · ensure equipment and furniture is in good repair. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a), part (2). Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment as required. The license holder failed to establish a policy and procedures related to suspected or alleged maltreatment that: · identified the secondary person or position to whom internal reports may be made and the secondary person or position responsible for forwarding the internal reports to the common entry point; and · identified the secondary person or position who will ensure that, when required, internal reviews are completed.
The license holder’s policy identified the “Center Director” as the primary position and the “Owner” as the secondary position; however, these positions were both held by the authorized agent. Corrective Action Ordered: Immediately, you must update establish policies and procedures related to suspected or alleged maltreatment that: · identifies the secondary person or position to whom internal reports may be made and a secondary person or position responsible for forwarding the internal reports to the common entry point; and · identifies the secondary person or position who will ensure that, when required, internal reviews are completed. Additionally, you must post a copy of the internal and external reporting policies and procedures in a prominent location in the center. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish and enforce their 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 most recently documented a review of the PAPP on April 23, 2019. 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 on site. On an ongoing basis, you must maintain 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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