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August 29, 2025 Laxmi Pokhrel, Authorized Agent Diversity Adult Daycare Services 360 Skillman Avenue East License Number: 1099211 (Rule 223) CORRECTION ORDER Dear Laxmi Pokhrel: On August 14, 2025, a licensing review of Diversity Adult Daycare Services located at 360 Skillman Avenue 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 Rules, part 9555.9660, subpart 1. Violation: For four of four participants whose records were reviewed (P1, P2, P3, and P4), the license holder did not include information in the participant’s written record as required. a. The license holder did not include the following information in P1’s record: · an application form that included the name and telephone number of a second person to call in case of emergency involving P1 if the first person cannot be reached; · a medical report, dated within the three months prior to or 30 days after P1’s admission to the center; and · participation reports and progress notes that are recorded at least monthly. b. The license holder did not include the following information in P2’s record: · an application form that included the 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; and · participation reports and progress notes that are recorded at least monthly. c. The license holder did not include the following information in P3’s record: · an application form that included: o the name and telephone number of a second person to call in case of emergency involving P3 if the first person cannot be reached; o the name and telephone number of P3’s physician or medical provider; · a medical report, dated within the three month prior to or 30 days after P3’s admission to the center; and · participation reports and progress notes that are recorded at least monthly. d. The license holder did not include the following information in P4’s record: · an application form that included: o the name and telephone number of a second person to call in case of emergency involving P4 if the first person cannot be reached; o the name of P4’s physician or medical provider; · a medical report, dated within the three months prior to or 30 days after P4’s admission to the center; and · participation reports and progress notes that are recorded at least monthly. Repeat Violation: In an Order of Conditional license that DHS issued on October 20, 2023, 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, P2, P3, and P4’s participant records. On an ongoing basis, you must maintain compliance as required in this subpart. 2. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For four participants whose records were reviewed (P1, P2, P3, and P4), the license holder did not complete initial service planning as required. The license holder did not conduct needs assessments for P1, P2, P3, and P4 that included the participants’ physical status from the medical reports received from P1, P2, P3, and P4’s physicians. Repeat Violation: In an Order of Conditional license that DHS issued on October 20, 2023, 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, P3, and P4’s needs assessments to include the participant’s physical status based on the information received from the participant’s medical report. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For three of three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation to the center as required. The license holder did not provide SP1-SP3 orientation to the center, including: · at least 4 hours of supervised orientation before the employee worked directly with persons at the center; and · orientation to the license holder’s Program Abuse Prevention Plan within 72 hours of first providing direct contact. Repeat Violation: In an Order of Conditional license that DHS issued on October 20, 2023, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1-SP3 the above required orientation. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (f), and section 245A.07, subdivision 3, paragraph (d). Violation: For one staff person whose record was reviewed (SP1), the license holder did not initiate a background study as required. SP1 began a position allowing direct contact with persons served by the program on November 12, 2024. However, the license holder did not initiate a background study for SP1 until March 20, 2025. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), except for background study violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a background study violation before the Commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a background study violation may not avoid a fine for a subsequent background study violation unless at least 365 days have passed since the license holder self-corrected the earlier background study violation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (d). Violation: The license holder did not have a grievance procedure as required. The license holder did not have a grievance procedure that identified the highest level of authority in the program. Corrective Action Ordered: Within 30 days of receiving this order, you must update your grievance procedure to include the highest level of authority in the program. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. 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. 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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