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September 14, 2022 Abdullahi Hussein, Authorized Agent Mercy Adult Daycare Center LLC 2700 Cardinal Avenue Suite B Faribault, Minnesota 55021 License Number: 1102784 (Rule 223) CORRECTION ORDER Dear Abdullahi Hussein: On September 13, 2022, a licensing review of Mercy Adult Daycare Center LLC, located at 912 East 24th Street, Minneapolis, 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 Rules, part 9555.9660, subpart 1. Violation: For three of five participants whose records were reviewed (P1, P2, and P4), the license holder did not include information in the participant’s written record as required. a. At the time of the licensing review, P1 was discharged from the center. The license holder failed to maintain a completed discharge summary in P1’s participant record. b. The license holder failed to maintain a medical report for P2 dated within the three months prior to or 30 days after P2’s admission to the center. P2 was admitted to the center on December 27, 2021; however, the license holder maintained a medical report for P2 dated March 20, 2022. c. The license holder failed to maintain a medical report for P4 dated within the three months prior to or 30 days after P4’s admission to the center. P4 was admitted to the center on January 3, 2022; however, the license holder maintained a medical report for P4 dated April 26, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a discharge summary in P1’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 2. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P2 and P4), the license holder did not complete initial service planning as required. a. The license holder failed to: · conduct a needs assessment for P2 that addressed P2’s physical status using information from the medical report received from P2’s physician. The license holder conducted P2’s needs assessment on December 27, 2021; however, the license holder did not receive the medical report from P2’s physician until March 20, 2022; and · develop a preliminary service plan for P2 that included P2’s nutritional needs and, where applicable, dietary restrictions. P2’s medical report, dated March 20, 2022, states that P2 is on a pork free diet; however, this was not included in P2’s preliminary service plan. b. The license holder failed to conduct a needs assessment for P4 that addressed P4’s physical status using information from the medical report received from P4’s physician. The license holder conducted P4’s needs assessment on January 3, 2022; however, the license holder did not receive the medical report from P4’s physician until April 26, 2022. Correction Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P2 and P4 using information from the medical report received from P2 and P4’s physicians; and · develop a preliminary service plan for P2 including the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For two consultants whose records were reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain a current and accurate copy of a signed contract or letter of appointment specifying conditions and terms of employment in the physical therapist and registered dietician’s personnel records. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a current and accurate copy of a signed contract or letter of appointment with your physical therapist and registered dietician specifying conditions and terms of employment. On an ongoing basis, you must maintain compliance as required in this item. 4. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to the center as required. a. The license holder failed to provide SP1 with 20 hours of orientation to the center within SP1’s first 40 hours of employment at the center. The license holder maintained documentation that SP1 was provided 17 hours of orientation to the center. Additionally, the license holder failed to provide SP1 orientation, including training related to the kinds of functional impairments of persons currently at the center. b. The license holder failed to provide SP2 with 20 hours of orientation to the center within SP2’s first 40 hours of employment at the center. The license holder maintained documentation that SP2 was provided 14 hours of orientation to the center. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraphs (a) and (b). Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder’s policy and procedures related to suspected or alleged maltreatment failed to: · identify the secondary person or position to whom internal reports may be made and the secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5; · identify the secondary person or position who will ensure that, when required, internal reviews are completed. The license holder’s policy identified the “director” as the primary position and the “owner” as the secondary position, however, these positions were both held by SP1. Corrective Action Ordered: Immediately, you must ensure the policy and procedures listed above are established as required in this subdivision. A copy of the policies and procedures must be posted in a prominent location in the program. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9555.9720, subpart 8. Violation: The license holder did not ensure safety as required. The license holder failed to ensure the areas used by participants were free from loose plaster. At the time of the licensing review, the following was observed: • an outlet in the men’s restroom did not have an outlet cover, resulting in exposed plaster; and • holes in the wall of the men’s restroom where a paper towel dispenser had previously been installed. Corrective Action Ordered: Immediately, you must ensure all areas used by participants are free from loose plaster. 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 regarding this Correction Order, please contact me as soon as possible. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6591
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