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October 6, 2022 Abdirisak Hassan, Authorized Agent Amaana Adult Daycare Center Inc. 1411 East 25th Street Minneapolis, Minnesota 55404 License Number: 1081860 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Abdirisak Hassan:
On July 28, 2022, as a result of a licensing review, a Correction Order was issued to Amaana Adult Daycare Center Inc., located at 1312 East Lake Street, Minneapolis, Minnesota. You were ordered to take corrective action for violations determined under citations 1 through 11. On October 4, 2022, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 3, 4, 6, 8, 9, and 11, it was determined that corrective action has not been achieved. As a result, this Notice of Noncompliance and 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 a 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 of state and federal laws and rules was 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. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For two participants whose records were reviewed (P2 and P4), 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 telephone number of the department’s licensing division to P2 upon admission. b. The license holder failed to distribute the following policies and procedures to P4 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; · 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. c. The license holder failed to distribute the participants' rights to P4 at admission. Corrective Action Ordered: Immediately, you must: · distribute the telephone number of the department’s licensing division to P2; · distribute the policies and procedures and participants’ rights listed above to P4; and · document the distribution of the applicable policies and procedures and participants’ rights in P2 and P4’s records. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2 and P4’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. License Holder Response: At the time of the follow-up licensing review on October 4, 2022, the license holder stated P2 was no longer receiving adult day services and no corrective action was required. The license holder distributed policies and procedures and participants’ rights to P4. DHS Response: The license holder failed to distribute the telephone number of the department’s licensing division to P4. Corrective Action Ordered: Within 15 days of receiving this order, you must distribute the telephone number of the department’s licensing division to P4. On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. Violation: For three 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, the license holder stated P1 was no longer receiving adult day services; however, the license holder failed to include a discharge summary in P1’s record. 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 date of birth, sex, and date of admission or readmission; · 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 P4’s record: · an application form signed by P4 or P4’s caregiver that included: o P4's name, address, date of birth, sex, date of admission or readmission, living arrangement, telephone number, and source of referral; o the name and telephone number of the person to call in case of an emergency involving P4 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P4's physician or medical provider; · P4's service agreement with the center that specified the responsibilities of P4 and the center with respect to payment for and provision of services and was signed by P4 or P4'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 P4 at the time of P4's admission specifying the basis on which P4 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. d. The license holder failed to provide P4 with written notice that ensured P4 was informed of P4's right to contest the accuracy and completeness of the data maintained in the record. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2 and P4’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. License Holder Response: The license holder maintained a discharge summary in P1’s record. At the time of the follow-up licensing review on October 4, 2022, the license holder stated P2 was no longer receiving adult day services and maintained a discharge summary in P2’s record. The license holder maintained the following information in P4’s record: · an application form; · P4's service agreement with the center that specified the responsibilities of P4 and the center with respect to payment for and provision of services and was signed by P4 or P4's caregiver and the center director; · notes on special problems, medication changes, and need for medication assistance; · a statement signed by the center director and P4 at the time of P4's admission specifying the basis on which P4 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions; and · written notice that P4 was informed of P4's right to contest the accuracy and completeness of the data maintained in the record. DHS Response: Although the license holder maintained an application form in P4’s record, the license holder failed to include P4’s source of referral and the name and telephone number of the secondary person to call in case of an emergency involving P4. Corrective Action Ordered: Within 15 days of receiving this order, you must update P4’s application form to include P4’s source of referral and the name and telephone number of the secondary person to call in case of an emergency involving P4. On an ongoing basis, you must maintain compliance as required in these subparts. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (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 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; · 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 a written plans of care for P2 and P3 that include the information detailed 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 30 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 subpart. License Holder Response: At the time of the follow-up licensing review on October 4, 2022, the license holder stated P2 was no longer receiving adult day services and no corrective action was required. The license holder reviewed P3’s written plan of care. DHS Response: The license holder failed to revise P3’s written plan of care to include: · an update of the preliminary service plan and additional services required by P3; and · short and long term objectives for P3 stated in concrete, measurable and time specific outcomes. Corrective Action Ordered: Within 15 days of receiving this order, you must revise P3’s written plan of care to include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain the following in SP1’s personnel record: · a job description; · documentation of an annual performance evaluation in 2020 and 2021; and · accurate documentation of completion of the annual in service training. The license holder maintained certificates that documented SP1 received 8 hours of training on January 2, 2020 and January 3, 2022; however, the license holder also maintained a document titled “Annual Training Report” that documented SP1 received 7.5 hours of training on January 2, 2020 and January 3, 2022. b. The license holder failed to maintain the following in SP2’s personnel record: · documentation of an annual performance evaluation in 2019, 2020, and 2021; and · accurate documentation of completion of the annual in service training. The license holder maintained certificates that documented SP2 received 8 hours of training on January 11, 2019, January 2, 2020, and January 3, 2022; however, the license holder also maintained a document titled “Annual Training Report” that documented SP2 received 7.5 hours of training on January 11, 2019, January 2, 2020, and January 3, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP1’s personnel record; and · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’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. License Holder Response: The license holder did not take corrective action as ordered. DHS Response: The license holder failed to: · maintain a job description in SP1’s personnel record; and · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record. Corrective Action Ordered: Within 15 days of receiving this order, you must: · maintain a job description in SP1’s personnel record; and · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For one consultant whose record was reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the registered nurse’s personnel record. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a copy of a signed contract or letter of appointment with your registered nurse specifying conditions and terms of employment. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. License Holder Response: The license holder did not take corrective action as ordered. DHS Response: The license holder failed to maintain a copy of a signed contract or letter of appointment with the registered nurse specifying conditions and terms of employment. Corrective Action Ordered: Within 15 days of receiving this order, you must maintain a copy of a signed contract or letter of appointment with your registered nurse specifying conditions and terms of employment. On an ongoing basis, you must maintain compliance as required in this item. 11. Citation: Minnesota Rules, part 9555.9720, subparts 3, 7, 8, and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to have the emergency phone numbers of P4’s caregiver, the persons to be called if the caregiver cannot be reached, and P4's physician readily available at the center. b. The license holder failed to ensure equipment and furniture were in good repair. A broken recliner was observed in an area used by participants. c. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint. Peeling paint was observed in multiple restrooms in the center and chipped or damaged walls were observed throughout the center. d. The license holder failed to ensure rugs throughout the center had nonskid backing. e. The license holder failed to rehearse the fire escape plan at least four times in 2020 and 2021. Corrective Action Ordered: Immediately, you must: · have the emergency phone numbers of P4’s caregiver, the persons to be called if the caregiver cannot be reached, and P4's physician readily available at the center; · ensure equipment and furniture is in good repair and remove all equipment or furniture that is not in good repair; · ensure all areas used by participants are free from debris and peeling paint; and · ensure rugs have nonskid backing. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. License Holder Response: The license holder made emergency phone numbers of P4’s caregiver and physician readily available at the center. Additionally, the license holder removed all furniture from the center that was not in good repair. DHS Response: The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint. Additionally, the license holder failed to ensure all rugs throughout the center had nonskid backing. Corrective Action Ordered: Immediately, you must: · ensure all areas used by participants are free from loose plaster and peeling paint; and · ensure rugs have nonskid backing. Within 30 days of receiving this order, you must submit photos to your licensor demonstrating action was taken to correct loose plaster and peeling paint. On an ongoing basis, you must maintain compliance as required in these subparts. 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, section 245A.06 and 245A.07. Submissions required as part of a corrective action ordered must be sent to your Licensor at: Commissioner, Department of Human Services ATTN: Desiree Tiller Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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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