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July 28, 2022 Faarah Hassan, Authorized Agent Diversity Adult Daycare Services Inc. 3845 Hiawatha Avenue Apt 428 Minneapolis, Minnesota 55406 License Number: 1099211 (Rule 223) CORRECTION ORDER Dear Faarah Hassan: On July 26, 2022, a licensing review of Diversity Adult Daycare Services Inc., located at 962 University Avenue, St. Paul, 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.04, subdivision 7a, paragraph (b). Violation: The license holder did not notify the commissioner before making any change to the license holder’s controlling individuals as required. At the time of the licensing review, SP2 informed DHS licensors that SP2 was one of three owners of the adult day center; however, SP2 was the only controlling individual on the license. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the names of all controlling individuals to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. 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 failed to maintain documentation of actual attendance for each adult day service recipient for which the license holder was reimbursed by a governmental program that included the first, middle and last name of the recipient. Corrective Action Ordered: Immediately, you must maintain documentation as required in this subdivision. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For 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 failed to develop and IAPP for P1 as part of P1’s initial individual program plan or service plan. b. The license holder failed to review P2 and P3’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained documentation that P2’s IAPP was most recently reviewed on February 2, 2022. · The license holder maintained documentation that P3’s IAPP was most recently reviewed on April 7, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P1; Additionally, you must review P1’s IAPP with P1’s interdisciplinary team and document the review; and · review P2, and P3’s IAPP with the persons’ 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. 4. 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 procedures to participants and their caregivers upon admission as required. a. The license holder failed to distribute the following policies and procedures to P1 and their caregivers upon admission: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. b. The license holder failed to distribute the participants' rights to P2 and their caregivers upon admission. Corrective Action Ordered: Immediately, you must: · distribute the policies and procedures listed above to P1 and their caregivers and document the distribution of the policies and procedures in P1’s record; and · distribute the participants’ rights to P2 and P2’s caregivers and document the distribution of the participants’ rights in P2’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part. 5. 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 failed to include the following information in P1’s record: · an application form signed by P1 or P1’s caregiver that included P1’s date of admission or readmission, living arrangement and source of referral; · 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, that included: o a report on a physical examination, updated annually; o a medical history of P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · 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 and was signed by P1 or P1's caregiver and the center director; · attendance and participation reports and progress notes that are recorded at least monthly; · notes on special problems, medication changes, and need for medication assistance; and · a statement signed by the center director and P1 at the time of P1's admission specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. b. The license holder failed to include the following information in P2’s record: · an application form signed by P2 or P2’s caregiver that included P2's telephone number and source of referral; · 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; and o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; · 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 and was signed by P2 or P2's caregiver and the center director; · notes on special problems, medication changes, and need for medication assistance; and · a statement signed by the center director and P2 at the time of P2's admission specifying the basis on which P2 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. c. The license holder failed to include the following information in P3’s record: · an application form signed by P3 or P3’s caregiver that included a source of referral; · a medical report, dated within the three months prior to or 30 days after P3’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 P3; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P3; and o documentation that P3 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · P3's service agreement with the center that specified the responsibilities of P3 and the center with respect to payment for and provision of services and was signed by P3 or P3's caregiver and the center director; and · attendance and participation reports and progress notes that are recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2, and P3’s participant record. 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 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder failed to conduct needs assessments for P1, P2, and P3 that included: · the participant’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization);§ · the participant’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · §the participant’s physical status, determined by observation, from the intake screening interview, and from the medical report received from the participant’s physician. b. The license holder failed to develop preliminary service plans for P1, P2, and P3 based on the assessment in item A and coordinated with other plans of service for P1, P2, and P3 within 30 days of the participant’s admission that included: · scheduled days of the participant’s attendance at the center; · transportation arrangements for getting the participant to and from the center; · the participant’s nutritional needs and, where applicable, dietary restrictions; · role of the participant’s caregiver or caregivers in carrying out the service plan; and · services and activities in which the participant would take part immediately upon admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1, P2, and P3 as detailed above; and · develop preliminary service plans for P1, P2, and P3 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. 7. 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 failed to develop written plans of care for P1, P2, and P3 that included§: · an update of the preliminary service plan 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 revisions of the individual plan of care. §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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to offer a midmorning and a midafternoon snack. The license holder’s menus indicated one snack was offered. b. The license holder failed to offer health services developed in consultation with a registered nurse, and reviewed by the registered nurse at least monthly, that included: · monitoring participants' health status and reporting changes to the participant's caregiver and physician and the center director; · educating and counseling participants on good health practices; · maintaining a listing of professional health resources available for referrals as needed by participants; · 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 participant self administration of medication and ensuring compliance with part 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. d. The license holder failed to maintain a family and social history in P1, P2, and P3’s records. § Corrective Action Ordered: Immediately, you must offer a midmorning and midafternoon snack. Within 30 days of receiving this order, you must: · offer health services as detailed above; · have your physical therapist provide consultation and review of the exercise program; and · maintain a family and social history in P1, P2 and P3’s records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For three of three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain a personnel record for SP1 that included documentation of an annual performance evaluation. b. The license holder failed to maintain a personnel record for SP2 that included: · SP2’s job description; · an employment application or resume indicating that SP2 met the requirements in part 9555.9680, subpart 2; and · documentation of an annual performance evaluation. c. The license holder failed to maintain a personnel record for SP3 that included SP3’s job description and documentation of an annual performance evaluation. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in SP1, SP2, and SP3’s personnel records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 10. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For three consultants whose records were reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain the following in the registered nurse, physical therapist, and registered dietician’s personnel records: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the following in your registered nurse, physical therapist, and registered dietician’s personnel records: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant meets licensure, registration, and certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation and annual review to a mandated reporter as required. The license holder failed to provide SP1, SP2, and SP3 orientation and annual review to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's program abuse prevention plan, 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 SP1, SP2, and SP3 the required review detailed above. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1, SP2, and SP3 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least four hours of supervised orientation before the employee worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1, SP2, and SP3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 13. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For three staff persons whose records were reviewed (SP1, SP2, and SP3), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1, SP2, and SP3 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1, SP2, and SP3. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 14. Citation: Minnesota Rules, part 9555.9720, subparts 8 and 9. 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 debris. b. The license holder failed to rehearse the fire escape plan at least four times in 2020 and 2021. Corrective Action Ordered: Immediately, you must: · ensure all areas used by participants are free from debris and peeling paint; and · rehearse your fire escape plan and record the date of the rehearsal in the file of emergency plans. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 15. Citation: Minnesota Rules, part 9555.9730, subpart 3. Violation: The license holder did not equip restrooms used by participants with a mechanism that participants could use to signal staff members by light or by sound if participants needed assistance as required. Corrective Action Ordered: Immediately, you must equip restrooms used by participants 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. 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General
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