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May 16, 2025 Tracy Vangh, Authorized Agent North Star Health Alliance LLC 388 Western Avenue North Suite B Saint Paul, Minnesota 55103 License Number: 1095876 (Rule 223) CORRECTION ORDER Dear Tracy Vangh: On April 24, 2025, a licensing review of North Star Health Alliance located at 388 Western Avenue North, 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 Rules, part 9555.9660, subpart 1 and 3. Violation: For four of four participants whose records were reviewed (P1-P4), the license holder did not include information in the participant’s written record as required. a. The license holder failed to maintain the following information in P1’s record: · a medical report in P1’s record, dated within the three months prior to or 30 calendar 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; o P1’s medical history; o indication of dietary restriction 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 from 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. b. The license holder failed to include a medical report in P2 and P4’s records, dated within the three months prior to or 30 calendar days after the participants admission to the center. · P2 was admitted to the center on April 5, 2023, and the license holder maintained a medical report for P2 on August 31, 2023. · P4 was admitted to center on January 22, 2024, and the license holder maintained a medical report for P4 on April 8, 2024. c. The license holder failed to maintain a medical report in P3’s record that included a physical examination, updated annually. The most recent report on a physical examination that the license holder maintained for P3 was dated August 30, 2022. d. The license holder failed to provide P1, P2, and P4 with written notice that ensured the participant or participant’s caregiver had been informed of the participant’s right to contest the accuracy and completeness of the data maintained in the record. Repeat Violation: In a Correction Order that DHS issued on September 13, 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-P4’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 2. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, and P4), the license holder did not complete initial service planning as required. a. The license holder failed to: · conduct a needs assessment for P1 that included P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P1’s physician; and · develop a preliminary service plan for P1 that included P1’s nutritional needs, and where applicable, dietary restrictions. b. The license holder failed to conduct a needs assessment for P2 that addressed P2’s physical status using information from the medical report received from the P2’s physician. The license holder conducted P2’s needs assessment on April 5, 2023; however, the license holder did not receive the medical report from P2’s physician until August 31, 2023. c. The license holder failed to: · conduct a needs assessment for P4 that addressed P4’s physical status using information from the medical report received from P4’s physician. The license holder conducted P4’s needs assessment on January 22, 2024; however, the license holder did not receive the medical report from P4’s physician until April 8, 2024; and · develop a preliminary service plan for P4 that included P4’s nutritional needs, and where applicable, dietary restrictions. Repeat Violation: In a Correction Order that DHS issued on September 13, 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, P2, and P4’s needs assessments to include information from the medical report received from the participant’s physician; and · update P1 and P4’s preliminary service plan to include the participant’s nutritional needs, and where applicable, dietary restrictions. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, P2, and P4), 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 the participant stated in concrete, measurable and time specific outcomes; and · the staff members responsible for implementing the individual plan of care. b. The license holder failed to develop a written plan of care for P2 that included short and long term objectives for P2 stated in concrete, measurable, and time specific outcomes. c. The license holder failed to develop a written plan of care for P4 that included: · an update of the preliminary service plan and additional services required by P4; · short and long term objectives for the participant stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Repeat Violation: In a Correction Order that DHS issued on September 13, 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, P2, and P4 that include the information detailed above; · complete an audit of all participants’ written plans of care to 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 60 days receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9710, subpart 7. Violation: The license holder did not offer services as required. The license holder failed to maintain a family and social history in P3’s record that was updated annually. The license holder maintained documentation that P3’s family and social history was most recently reviewed in August 2023. Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must document the review of P3’s family and social history and update P3’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item A and B. Violation: For two of two staff persons (SP1 and SP2) and one consultant whose records were reviewed, the license holder did not maintain personnel files as required. a. The license holder failed to maintain documentation of an annual performance evaluation in SP1 and SP2’s personnel records. b. The license holder failed to maintain a personnel file for the physical therapist that included 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 annual performance evaluations in SP1 and SP2’s personnel records; and · maintain documentation that your physical therapist meets any licensure, registration, or certification requirements required to perform the service specified in the contract. On an ongoing basis, you must maintain compliance as required in these items. 6. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 and SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center. The license holder provided 16 hours of orientation to SP1 and 17 hours of orientation to SP2 within the first 40 hours of employment at the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. The license holder failed to maintain a current and accurate contract with their food service provider that prepared food off-site. Corrective Action Ordered: Immediately, you must maintain a current and accurate contract with a food service provider. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9720, subpart 8. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure the areas used by participants were free from debris and peeling paint. b. The license holder failed to ensure rugs has nonskid backing. Corrective Action Ordered: Immediately, you must: · ensure all areas used by participants are free from debris and peeling paint; and · ensure all rugs have nonskid backing. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).
The license holder failed to ensure the license holder’s governing body or the governing body’s delegated representative reviewed the PAPP annually.
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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