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January 9, 2024
Stuart Lindeman, Authorized Agent Mission Today 302 Knights Run Avenue Suite 900 Tampa, Florida 33602 License Number: 1073846 (Rule 223) NOTICE: This Amended Correction Order supersedes a Correction Order dated December 21, 2023, which must be destroyed. The original correction order failed to include the correct address of the authorized agent. Original Date Issued: December 21, 2023 Date Reissued: January 9, 2024 AMENDED CORRECTION ORDER Dear Stuart Lindeman: On November 9, 2023, a licensing review of Mission Today, located at 5430 Boone Avenue North, New Hope, 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 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For one of two participants whose record was reviewed (P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan (PAPP) as required. P2 was admitted to the center on October 20, 2023. Although the license holder maintained documentation that P2 was provided orientation to the licensor holder’s internal and external reporting procedures and PAPP, the license holder failed to document the date of the orientation; therefore, it was unable to be determined if P2 was provided the required orientation within 24 hours of P2’s admission to the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop IAPPs for P1 and P2 as part of their initial individual program plan or service plan.
Repeat Violation: In a Correction Order DHS issued on April 3, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, you must develop IAPPs for P1 and P2. Additionally, within 30 days of receiving this order you must: · review P1 and P2’s IAPPs with P1 and P2 and their 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. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required. The license holder maintained documentation in P1 and P2’s records that the required policies, program information, and participant’s rights were distributed to P1 and P2. However, the license holder failed to document the date of the distribution; therefore, it was unable to be determined if P1 and P2 received the policies, program information, and participants’ rights upon P1 and P2’s admission to the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2.
Violation: For one participant whose record was reviewed (P2), the license holder did not complete initial service planning as required. The license holder failed to develop a preliminary service plan for P2 that included: · scheduled days of P2’s attendance at the center; and · the role of P2’s caregiver or caregivers in carrying out the service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P2’s preliminary service plan to include the information and specifications detailed above; · complete an audit of all participants’ preliminary service plans to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 2 are maintained; and · for participants who do not have preliminary service plans that include all requirements, you must develop a plan detailing how your program will maintain a complete preliminary service plans 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 subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P1), the license holder did not complete initial service planning as required.
The license holder failed to develop the individual plan of care for P1 within 90 days of P1’s admission to the center that included: · an update of the preliminary service plan required in subpart 2 and additional services required by the participant; · short and long-term objectives for the participant 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 review and quarterly revision of the individual plan of care. Corrective Action Ordered: Within 30 days of receiving this order, you must develop an individual plan of care for P1 as detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For one of two staff persons (SP2) and the consultants whose records were reviewed, the license holder did not maintain personnel files as required. a. The license holder failed to maintain documentation of annual performance evaluations in SP2’s personnel record in 2021, 2022, and 2023. b. The license holder failed to maintain a personnel file for each consultant, including the registered dietician, registered nurse, and registered physical therapist, that included: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the person under contract met any licensure, registration, or certification requirements required to perform the services specified in the contract. Repeat Violation: In a Correction Order that DHS issued on April 3, 2019, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a performance evaluation for SP2 and maintain documentation of the evaluation in SP2’s personnel record; and · maintain a personnel file for each consultant that includes a copy of a signed contract or letter of appointment specifying conditions and terms of employment and documentation that the person under contract meets any licensure, registration, or certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide annual review to a mandated reporter as required. The license holder failed to provide SP2 annual review in 2021, 2022, and 2023 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. Corrective Action Ordered: Immediately, you must provide the required orientation and annual review detailed above to SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. 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 failed to provide SP2 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 in 2021, 2022, and 2023. Repeat Violation: In a Correction Order that DHS issued on April 3, 2019, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, and 4. Violation: The license holder did not offer services as required. a. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietician and met all applicable state rules and laws and United States Department of Agriculture regulation. b. The license holder failed to 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. c. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2021, 2022, and 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure: · your menus are approved by a registered dietician; · a registered nurse provides consultations and review of your health services; and · a registered physical therapist provides consultations and review of your exercise program. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 10. Citation: Minnesota Rules, part 9555.9720, subparts 8, 9, and 10. Violation: The license holder did not ensure safety as required.
a. The license holder failed to ensure the areas used by participants were free from peeling paint. b. The license holder failed to post the plans for emergencies caused by fire, blizzard, and tornadoes in a visible place in the center. c. The license holder failed to have written procedures governing medical emergencies. Corrective Action Ordered: Immediately, you must: · ensure the areas used by participants are free from peeling paint; · post the plan for emergencies caused by fire, blizzard, and tornadoes in a visible place in the center; and · develop procedures governing medical emergencies and make the procedures known to all staff members and volunteers. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not review their program abuse prevention plan (PAPP) as required. The license holder failed to 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 March 2019. 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 on site. 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 your licensor, Katie Johnson, at 651-431-4113. Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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