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September 26, 2022 Ramadan Adem, Authorized Agent Awash Care LLC 580 University Avenue West St. Paul, Minnesota 55103 License Number: 1103906 (Rule 223) CORRECTION ORDER Dear Ramadan Adem: On September 22, 2022, a licensing review of Awash Care LLC, located at 580 University Avenue West, 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.65, subdivision 2, paragraph (b). Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop IAPPs for P1 and P2 as part of the person’s initial individual program plan or service plan and failed to review P1 and P2’s IAPPs quarterly as part of the review of the program plan or service plan. The license holder failed to document dates on P1 and P2’s IAPPs; therefore the dates that P1 and P2’s IAPPs were developed and reviewed were unable to be determined. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P1 and P2’s IAPPs with the person’s 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. 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. The license holder failed to include participation reports and progress notes in P1 and P2’s records that were recorded at least monthly in July and August 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this part. 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. P1’s admission date was March 14, 2022. The license holder failed to develop a preliminary service plan for P1 within 30 days of P1’s admission that included: · scheduled days of P1’s attendance at the center; · transportation arrangements for getting P1 to and from the center; · P1’s nutritional needs and, where applicable, dietary restrictions; · role of P1’s caregiver or caregivers in carrying out the service plan; and · services and activities in which P1 would take part immediately upon admission. b. The license holder failed to conduct a need assessment for P2 that included P2's physical status determined from the medical report received from P2’s physician. The license holder conducted P2’s needs assessment on April 7, 2022; however, the license holder did not receive the medical report from P2’s physician until April 22, 2022. c. The license holder failed to develop a preliminary service plan for P2 that accurately included information about P2’s nutritional needs and, where applicable, dietary restrictions. The license holder documented that P2 had a “low salt” diet in P2’s preliminary service plan; however, P2’s medical report did not reference a low salt diet. Corrective Action Ordered: Within 30 days of receiving this order, you must develop preliminary service plans for P1 and P2 that include the information and specifications detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), 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 and P2 that included§: · short and long term objectives for the participant stated in concrete, measurable and time specific outcomes; 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 and P2 that include the information listed above; · complete an audit of all participants’ written plans of care to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained; and · for participants who do not have a written plan of care that includes all required information, you must develop a plan detailing how your program will maintain a complete written plan of care within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9710, subpart 3. Violation: The license holder did not offer services as required. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly. At the time of the licensing review, SP1 was asked to provide documentation or dates of when the registered nurse provided consultation and review of the health services, but SP1 was not able to provide this information. § Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not maintain a program abuse prevention plan (PAPP) as required. The license holder failed to review the PAPP at least annually. The most recent review of the PAPP was dated January 27, 2020. 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 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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