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March 6, 2025
Pathstone Day Living 3530 Lexington Avenue North License Number: 801477 (Rule 223) CORRECTION ORDER Dear Loretta Lewis: On January 22, 2025, a licensing review of Pathstone Day Living located at 718 Mound Avenue, Mankato, 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.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For one of three participants whose records were reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP).
The license holder failed to review P1’s IAPP quarterly as part of the review of the program plan of service plan. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision and rule. 2. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one participant whose records was reviewed (P3), the license holder did not meet the requirements for positive support strategies as required. The license holder failed to evaluate positive support strategies with P3 and determine whether changes were needed to the identified positive support strategies at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate the positive support strategies with P3 and document the review in P3’s record; and · based on the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. Additionally, you must: · at least every six months, evaluate with P3 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 appropriate changes; · at least every six months, evaluate with P3 whether the services support P3’s preferences, daily needs and activities, and the accomplishment of P3’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 subpart. 3. Citation: Minnesota Rules, part 9544.0070. Violation: The license holder did not meet the requirements for the emergency use of manual restraint as required. The license holder did not develop, document, and implement a policy and procedures that promoted service recipient rights and protect health and welfare during the emergency use of manual restraint as required in Minnesota Statutes, section 245D.061, subdivision 9. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a policy and procedures on the emergency use of manual restraint; · provide notice to P3 of your policy and procedures on the emergency use of manual restraint as required in part 9544.0080. The notice must: o inform P3 of their rights under Minnesota Statutes, section 245D.04; and o be in writing; and · obtain written acknowledgement from P3 that P3 has been notified. On an ongoing basis, you must maintain compliance as required in this part and subdivision.
4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, P2, and P3), 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, P2, and P3 that included an update of the preliminary service plan and additional services required by the participant. Repeat Violation: In a Correction Order that DHS issued on June 27, 2022, you were previously found in violation of this same rule. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP2 orientation to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact. Corrective Action Required: Immediately, you must provide the required orientation detailed above to SP2. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP2 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 SP2 worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Corrective Action Required: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP2. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9720, subpart 9. Violation: The license holder did not ensure safety as required. The license holder failed to ensure the dates of the fire drill rehearsals were recorded in the file of emergency plans.
8. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not meet the requirements for the program abuse prevention plan (PAPP). The license holder failed to ensure a copy of the PAPP was posted in a prominent location within the center. Corrective Action Ordered: Immediately, you must post a copy of your PAPP in a prominent location within the center. 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. Alexandra Devick, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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