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August 8, 2025
Nay Moe, Authorized Agent Karen Myanmar Senior Center 1741 City Heights Drive Maplewood, Minnesota 55117 License Number: 1088220 (Rule 223) CORRECTION ORDER Dear Nay Moe: On July 16, 2025, a licensing review of Karen Myanmar Senior Center, located at 1059 Viking Drive East, Maplewood, 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 license holder did not 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: Within 30 days of receiving this order, you must maintain documentation of actual attendance for each adult day service recipient. 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 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 did not review P1 and P2’s IAPPs quarterly as part of the review of the program plan or service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must review P1’s IAPP with P1’s interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision and subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P3), the license holder did not develop a written plan of care as required. a. The license holder did not develop a written plan of care for P1 that included: · an update of the preliminary service plan and additional services required by P1; · the anticipated duration of the individual plan of care as written; and · provisions for quarterly review and quarterly revisions of the individual plan of care. b. The license holder did not develop a written plan of care for P3 that included: · an update of the preliminary service plan and additional services required by P3; and · the anticipated duration of the individual plan of care as written. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1 and P3 that include the information listed above; · complete and 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 of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9710, subparts 1, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder did not maintain a contract with the food service provider. b. The license holder did not ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2023 and 2024. c. The license holder did not maintain family and social histories in P1 and P2’s record that were updated annually. · P1’s family and social history was most recently reviewed on April 19, 2024; and · P2’s family and social history was most recently reviewed on April 11, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a contract with your food service provider; · ensure your physical therapist provides consultation and review of your exercise program; and · maintain an updated family and social history in P1 and P2’s record. On an ongoing basis, you must maintain compliance as required in these subparts. 5. Citation: Minnesota Rules, part 9555.9720, subparts 7 and 9. Violation: The license holder did not meet safety requirements. a. The license holder did not ensure furniture is in good repair including massage chairs and couches. b. The license holder did not have written plans for emergencies caused by fire that included: · procedures for the quarterly fire drill; · instructions on location and use of fire extinguishers; and · instructions on closing off the fire area. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure furniture is in good repair; and · develop written plans for emergencies caused by fire that include the information detailed above. On an ongoing basis, you must maintain compliance as required in these subparts. 6. Citation: Minnesota Rules, part 9555.9730, subpart 3. Violation: The license holder did not ensure physical plant and space requirements. The license holder did not 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: Within 30 days of receiving this order, you must ensure the restroom used by participants are equipped with a mechanism that participants can use to signal staff members by light or by sound if participants need assistance. On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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 did not identify a consistent primary person or position and secondary person or position to whom internal reports may be made and responsible for forwarding the internal reports to the common entry point. Corrective Action Ordered: Within 30 days of receiving this order, you must update your policies and procedures related to suspected or alleged maltreatment of vulnerable adults. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. 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 did not 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 in March 2023.
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. 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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