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March 5, 2025
Pathstone Day Living 3530 Lexington Avenue North License Number: 1117339 (Rule 223) CORRECTION ORDER Dear Loretta Lewis: On January 22, 2025, a licensing review of Pathstone Day Living located at 1114 West Traverse Road, Saint Peter, 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 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For one of three participants whose record was reviewed (P2), the license holder did not provide orientation to the internal and external reporting procedures related to suspected or alleged maltreatment and program abuse prevention plan (PAPP) as required. The license holder failed to provide P2 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment and PAPP within 24 hours of admission. Corrective Action Ordered: Immediately, you must provide P2 an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment and PAPP. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one participant whose record was reviewed (P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop an IAPP for P2 as part of P2’s initial individual program plan or service plan. P2 was admitted on April 18, 2024. The license holder maintained documentation that P2’s IAPP was developed on May 31, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P2), the license holder did not meet the policy and program information requirements. The license holder failed to distribute the following to P2 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; · procedure for presenting grievances, including the name, address, and telephone number of the licensing division of the department, to which a participant or participant’s caregiver may submit an oral or written complaint; · a copy or written summary of Minnesota Statutes, section 626.557, the Vulnerable Adults Act; · 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. Corrective Action Ordered: Immediately, you must provide P2 with the policy and program information detailed above and document that distribution in P2’s record. On an ongoing basis, you must maintain compliance as required in this rule. 4. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For one participant whose record was reviewed (P2), the license holder did not include information in the participant’s written record as required. The license holder failed to include the following information in P2’s record: · 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; o a medical history of P2; o indication of dietary restrictions 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 o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · notes on special problems, medication changes, and need for medication assistance; and · a statement signed by the center director and P2 at the time of P2’s admission specifying the basis on which P2 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P2’s record. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P2), the license holder did not complete initial service planning as required. P2 was admitted to the center on April 18, 2024. The license holder failed to: · conduct a needs assessment for P2 within 30 days of P2’s admission to the center that included P2’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P2’s physician; and · develop a preliminary service plan for P2 within 30 days of admission that included: o scheduled days of P2’s attendance at the center; o transportation arrangements for P2 to and from the center; o P2’s nutritional needs, and where applicable, dietary restrictions; o the role of P2’s caregiver or caregivers in carrying out the service plan; and o service and activities in which P2 would take part immediately upon admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P2’s needs assessment to include P2’s physical status based on the information received from P2’s medical report; and · develop a preliminary service plan for P2 that includes the information and specifications detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 6. 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. a. The license holder failed to develop a written plan of care for P1 that included short and long term objectives for P1 stated in concrete, measurable and time specific outcomes. b. The license holder failed to develop written plans of care for P2 and P3 that included: · an update of the preliminary service plan and additional services required by the participant; and · short and long term objectives for P1 stated in concrete, measurable and time specific outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1, P2, and P3 that include the information listed above; · complete an audit of all participants’ written plans of care and ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained; and · for participants who do not have a written plan of care that includes all required information, you must develop a plan detailing how your program will maintain a complete written plan of care within 30 days of receiving this order. 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.
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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