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December 22, 2025
Matthew Fischer, Authorized Agent Bethany Adult Day Services 1020 Lark Street Alexandria, Minnesota 56308 License Number: 1091727 (Rule 223) CORRECTION ORDER Dear Matthew Fischer: On November 12-13, 2025, a licensing review of Bethany Adult Day Services, located at 1020 Lark Street, Alexandria, 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 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.
2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For two of two participants whose records were reviewed (P1 and P2), 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 that included: · an individualized assessment of P1’s susceptibility to abuse by other individuals, including other vulnerable adults; · P1’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults. b. The license holder did not review P2’s IAPP quarterly as part of the review of the program plan or service plan. c. The license holder did not review P2’s IAPP with P2’s interdisciplinary team, at least annually, using the individual assessment and any reports of abuse relating to the person.
· review P2’s IAPP quarterly as part of the review of the program plan or service plan and document the review and date the review occurred; · review P2’s IAPP annually with P2’s interdisciplinary team and document the review; · complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and · for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision and subpart. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For one participant whose record was reviewed (P1), the license holder did not include information in the participant’s written record as required. The license holder did not include a medical report for P1 in P1’s participant record that was signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician. The license holder maintained a medical report for P1 that was signed by an advanced practice registered nurse and was not cosigned by a physician.
4. 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. a. 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: · P1 and P2’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · P1 and P2’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · P1 and P2's physical status, determined by observation, from the intake screening interview, and from the medical report received from P1 and P2's physicians. b. The license holder did not develop a preliminary service plan for P1 that included: · P1’s scheduled days of attendance at the center; and · P1’s transportation arrangements for getting P1 to and from the center. c. The license holder did not develop a preliminary service plan for P2 that included the role of P2’s caregiver or caregivers in carrying out the service plan.
· develop needs assessments for P1 and P2 that includes the information detailed above; · develop a preliminary service plan for P1 and P2 that includes the information detailed above. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), 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 and P2 that included: · an update of the preliminary service plan and additional services required by P1 and P2; · short and long term objectives for P1 and P2 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; and · provisions for quarterly reviews and quarterly revisions of the individual plan of care. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a written plan of care for P1 and P2 that includes the information detailed above. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For one of two staff persons (SP1) whose record was reviewed, the license holder did not maintain personnel files as required. The license holder did not maintain documentation of an annual performance evaluation in SP1’s personnel record in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’s personnel record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 7. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records was reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. The license holder did not provide SP1 and SP2 a minimum of eight hours of in-service training annually in the following areas: · areas related to care of center participants, including provision of medication assistance and review of parts 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1 and SP2. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9710, subparts 1 and 3. Violation: The license holder did not offer services as required. a. The license holder did not ensure the menus for all meals and snacks were approved by a registered dietician. b. The license holder did not ensure a registered nurse provided consultation and review of the health services at least monthly, that included: · monitoring a person’s health status and reporting changes to the person’s caregiver, physician, and center director; · educating and counseling persons on good health practices; · maintaining a listing of professional health resources available for referrals as needed by people; · developing policies and monitoring procedures for participant self-administration of medications for training unlicensed personnel who provide medication assistance; and; · supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 2, item C. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure the menus for all meals and snacks are approved by a registered dietician; and · ensure a registered nurse provides consultation and review of the health services at least monthly. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Rules, part 9555.9720, subpart 9.
Violation: The license holder did not meet safety requirements. The license holder did not ensure plans for emergencies caused by fire, blizzards, and tornadoes were posted in a visible place in the center. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure plans for emergencies caused by fire, blizzards, and tornadoes are posted in a visible place in the center. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 10. 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 restrooms 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. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2. 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. 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 and document the review. Compliance with this order will be reviewed onsite. 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. Katie Johnson, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4113
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