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September 11, 2026
Sacred Heart Adult Day Care License Number: 802174 (Rule 223) CORRECTION ORDER Dear Brittany Gast: On July 9, 2026, a licensing review of Sacred Heart Adult Day Care located at 1200 12th Street Southwest, Austin, 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 two of three participants whose records were reviewed (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 P2 and P3 as part of P2 and P3’s initial individual program plan or service plan that included: · an individualized assessment of P2 and P3’s susceptibility to abuse by other individuals, including other vulnerable adults; · P2 and P3’s risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P2 and P3 and other vulnerable adults. b. The license holder did not review P2 and P3’s IAPPs with P2 and P3’s interdisciplinary teams, at least annually, using the individual assessment and any reports of abuse relating to the person. Repeat Violation: In a Correction Order that DHS issued on July 10, 2024, you were previously found in violation of this same rule. · develop an IAPP for P2 and P3 that includes the information detailed above; · review P2 and P3’s IAPPs annually with P2 and P3’s interdisciplinary teams and document the reviews; · 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 onsite. On an ongoing basis, you must maintain compliance as required in this subdivision and subpart. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P2 and P3), 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 P2’s participant record: · an application form that included: o P2’s date of admission and source of referral; o the name and telephone number of the person to call in case of an emergency involving P2 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P2’s physician or medical provider. b. The license holder did not include a report on a physical examination, updated annually in P3’s participant record in 2025. Repeat Violation: In a Correction Order that DHS issued on July 10, 2024, you were previously found in violation of this same rule. 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. a. The license holder did not conduct a needs assessment for P1 within 30 days of P1’s admission to the center. The license holder maintained a needs assessment for P1 that was not dated; therefore, the date the needs assessment was conducted was unable to be determined. Additionally, the license holder did not include P1’s physical status from the medical report received from P1’s physician. b. 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 a need assessment for P1 that includes the information detailed above; · develop a preliminary service plan for 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. 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. a. The license holder did not develop a written plan of care for P1 that included short and long term objectives for P1 stated in concrete, measurable and time specific outcomes. b. 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; · short and long term objectives for P2 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · the anticipated duration of the individual plan of care as written. c. The license holder did not develop a written plan of care for P3 that included: · short and long term objectives for P3 stated in concrete, measurable and time specific outcomes; and · the anticipated duration of the individual plan of care as written. Repeat Violation: In a Correction Order that DHS issued on July 10, 2024, you were previously found in violation of this same rule. 5. Citation: Minnesota Rules, part 9555.9650, items A and B. a. The license holder did not maintain an employment application or resume for SP2 in SP2’s personnel record. b. The license holder did not maintain documentation of an annual performance evaluation for SP3 in SP3’s personnel record. The most recent documentation of an annual performance review for SP3 the license holder maintained was dated July 19, 2023. c. The license holder did not maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the physical therapist’s personnel record. d. The license holder did not maintain the following in the registered dietician’s personnel record: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the RD meets licensure, registration, or certification requirements required to perform the services specified in the contract. Corrective Action Required: Within 30 days of receiving this order, you must: · maintain an employment application or resume for SP2 in SP2’s personnel record; · maintain documentation of an annual performance evaluation for SP3 in SP3’s personnel record; · maintain a copy of the PT and RD’s signed contracts in the PT and RD’s personnel records; and · maintain documentation of the RD’s licensure, registration, or certification in the RD’s personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide annual review to a mandated reporter as required. The license holder did not provide SP3 annual review in 2026 to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder’s PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.
7. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide in-service training annually as required. a. The license holder did not provide SP2 in-service training annually in 2026 that included review of parts 9555.9600 to 9555.9730. b. The license holder did not provide SP3 eight hours of in-service training annually in 2026 that included: · areas related to care of persons; · including provision of medication assistance; and · review of parts 9555.9600 to 9555.9730.
8. Citation: Minnesota Rules, part 9555.9710, subparts 1, 4 and 7.
a. The license holder did not maintain a current contract with a food service provider. b. The license holder did not ensure the registered physical therapist provided consultation and review of the exercise program, at least quarterly in 2026. c. The license holder did not maintain a family and social history that was updated annually for P2 and P3. Repeat Violation: In a Correction Order that DHS issued on July 10, 2024, you were previously found in violation of this same rule.
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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