|
January 5, 2026
Touney Xiong, Authorized Agent Universal Adult Day Care Center LLC 1454 Kingswood Pond Overlook Eagan, Minnesota 55122 License Number: 1081612 (Rule 223) CORRECTION ORDER Dear Touney Xiong: On November 13, 2025, a licensing review of Universal Adult Day Care Center LLC, located at 7322 Lakeland Avenue North, Brooklyn Park, 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 3. Violation: For one of two staff person whose record was reviewed (SP2), the license holder did not provide mandated reporter orientation as required. The license holder did not provide SP2 orientation to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, all internal policies and procedures related to the prevention, and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact.
2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For four of five participants whose records were reviewed (P1, P3, P4, and P5), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder did not review P1’s IAPP quarterly as part of the review of the program plan or service plan. b. The license holder did not review P1, P3, P4 and P5’s IAPPs with their interdisciplinary teams, at least annually, using the individual assessment and any reports of abuse relating to the person.
· review P1’s IAPP quarterly as part of the review of the program plan or service plan and document the review; and · review P1, P3, P4, and P5’s IAPPs annually with their interdisciplinary team 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 and subpart. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P1 and P2), 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 participant record: · a medical report, dated within the three months prior to or 30 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; and · P1’s service agreement with the center, that specified the responsibilities of P1 and the center with respect to payment for and provision of services. b. The license holder did not include the following information in P2’s participant record: · a medical report, 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: o a report on a physical examination; updated annually; o a medical history of P2; o indication of dietary restrictions and medication regimen, including the need for medication assistance that apply to P2; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; o documentation that P2 was free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090 that would endanger the health of other participants; · notes on special problems or on changes needed in medication and on the need for medication assistance; and · P2’s service agreement with the center, that specified the responsibilities of P2 and the center with respect to payment for and provision of services. Repeat Violation: In a Correction Order that DHS issued on October 19, 2023, you were previously found in violation of this same rule. 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. 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 includes P1 and P2's physical status, determined by observation, from the intake screening interview, and from the medical reports received from P1 and P2's physicians.
5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (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 P2 that included an update of the preliminary service plan and additional services required by P2. Repeat Violation: In a Correction Order that DHS issued on October 19, 2023, you were previously found in violation of this same rule. 6. Citation: Minnesota Rules, part 9555.9650, items A and B.
Violation: For one staff person (SP1) and three consultants whose records were reviewed, the license holder did not maintain a personnel record as required. a. The license holder did not maintain a job description in SP1’s personnel record. b. The license holder did not maintain a personnel file for the physical therapist that included: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the physical therapist meets any licensure, registration, or certification requirements required to perform the services specified in the contract. c. The license holder did not maintain a personnel file for the registered nurse that included a copy of a signed contract or letter of appointment specifying conditions and terms of employment. d. The license holder did not maintain a personnel file for the registered dietician that included documentation that the registered dietician meets any licensure, registration, or certification requirement required to perform the service specified in the contract. Repeat Violation: In a Correction Order that DHS issued on October 19, 2023, 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 SP1, physical therapist, registered nurse, and registered dietician’s personnel records. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these items. 7. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide in-service training annually as required. The license holder did not provide SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide in-service training annually as required. The license holder did not provide SP1 a minimum of eight hours of in-service training annually in areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730. Repeat Violation: In a Correction Order that DHS issued on October 19, 2023, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 training in the areas detailed above and document the completed training in the SP1’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9720, subparts 1, 7, 8 and 9. Violation: The license holder did not meet safety requirements. a. The license holder did not have a first aid kit that contained a thermometer. b. The license holder did not ensure equipment and furniture was in good repair, including: · damaged ceiling tiles, · large stains on the carpet, · 25 recliners with peeling material; and · 67 sturdy chairs that were ripped and taped. c. The license holder did not ensure rugs had nonskid backing. d. The license holder did not ensure the areas used by participants were free from loose plaster and peeling paint. e. The license holder did not post written plans for emergencies in a visible place in the center. Repeat Violation: In a Correction Order that DHS issued on October 19, 2023, you were cited for a similar violation. Corrective Action Required: Within 30 days of receiving this order, you must: · ensure your first aid kit contains a thermometer; · ensure equipment and furniture is in good repair; · ensure rugs have nonskid backing; · ensure areas used by participants are free from loose plaster and peeling paint; and · post a copy of your written plans for emergencies in a visible place in your center. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 10. 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 January 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. Compliance with this order will be reviewed onsite. 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
|
