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December 2, 2025
Ecumen of Litchfield Adult Day Services 3530 Lexington Avenue North License Number: 1042946 (Rule 223) CORRECTION ORDER Dear Lori Lewis: On November 12, 2025, a licensing review of Ecumen of Litchfield Adult Day Services located at 200 North Holcombe Avenue, Litchfield, 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 three of three participants whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder did not develop an IAPP for P1 as part of P1’s initial individual program plan or service plan.
b. The license holder did not review P2 and P3’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: · develop an IAPP for P1 as part of their initial individual program plan or service plan; and · review P2 and P3’s IAPPs quarterly as part of their individual program plan or service plan and document the reviews. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not include information in the participant’s written record as required. a. The license holder did not maintain a medical report for P1 in P1’s participant record that was dated within the three months prior to or 30 days after P1’s admission to the center that included a release signed by the physician indicating whether P1 may engage in a structured exercise program. b. The license holder did not maintain a medical report for P2, that was 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: · a release signed by the physician indicating whether P2 may engage in a structured exercise program; and · 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. c. The license holder did not maintain a report on P3’s physical examination that was updated annually in 2025. The license holder maintained a physical examination for P3 that was dated January 2024. Repeat Violation: In a Correction Order that DHS issued on March 29, 2024, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P1, P2, and P3’s participant records. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not complete initial service planning as required. The license holder did not conduct a needs assessment for P1 and P2 within 30 days of P1 and P2’s admission to the center that included the participant’s physical status from the medical reports received from P1 and P2’s physicians. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1 and P2’s needs assessments to include P1 and P2’s physical status based on the information received from their medical reports. On an ongoing basis, you must maintain compliance as required in this subpart. 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 did not develop a written plan of care for P1, P2, and P3 that included: · short and long term objectives stated in concrete, measurable, and time specific outcomes; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Repeat Violation: In a Correction Order that DHS issued on March 29, 2024, 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 P3 that include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item A. The license holder did not maintain documentation of an employment application or resume for SP1 in SP1’s personnel record. Corrective Action Required: Within 30 days of receiving this order, you must maintain documentation of SP1’s employment application or resume in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Rules, part 9555.9710, subpart 4.
The license holder did not ensure the registered physical therapist provided consultation and review of the exercise program at least quarterly. The license holder maintained documentation that the exercise program was most recently reviewed in January 2024.
On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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 did not ensure the governing body or the governing body’s delegated representative reviewed the PAPP as least annually in 2025, using the assessment factors in the plan; and any substantiated maltreatment findings that occurred since the last review. The license holder maintained documentation that their PAPP was most recently reviewed in February 2024.
If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. 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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