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December 12, 2022 Suado Dirir, Authorized Agent Tranquility Adult Daycare Services LLC 1402 1st Avenue South Minneapolis, Minnesota 55403 License Number: 1082425 (Rule 223) CORRECTION ORDER Dear Suado Dirir: On December 7, 2022, a licensing review of Tranquility Adult Daycare Services LLC, located at 1402 1st Avenue South, 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 Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For five of five participants whose records were reviewed (P1, P2, P3, P4, and P5), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder maintained IAPPs for P1, P2, and P5 that were not dated; therefore, it was unable to be determined if the license holder developed P1, P2, and P5’s IAPPs as part of the initial individual program plan or service plan. b. The license holder failed to review P1, P2, P3, P4, and P5’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained documentation that P1’s IAPP was reviewed on February 8, 2022, June 6, 2022, and October 5, 2022. · The license holder maintained documentation that P2’s IAPP was reviewed on April 14, 2021, August 11, 2021, April 13, 2022, and August 8, 2022. · The license holder maintained documentation that P3’s IAPP was reviewed on January 11, 2021, April 14, 2021, December 13, 2021, and August 11, 2022. · The license holder maintained documentation that P4’s IAPP was reviewed on February 10, 2021, August 23, 2021, June 13, 2022, and October 10, 2022. · The license holder did not maintain documentation that P5’s IAPP was reviewed. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P2, P3, and P5’s IAPPs 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, subpart 1. Violation: For one participant whose record was reviewed (P1), the license holder did not include information in the participant’s written record as required. The license holder failed to include a medical report in P1’s record dated within the three months prior to or 30 days after P1’s admission. P1 was admitted to the center on July 12, 2021 and the license holder maintained a medical report for P1 on September 17, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 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. The license holder failed to conduct a needs assessment for P1 that included §P1's physical status, determined from the medical report received from P1's physician. The license holder conducted a needs assessment for P1 on August 10, 2021; however, the license holder did not maintain a medical report for P1 until September 17, 2021. b. The license holder failed to develop a preliminary service plan for P2 that included the role of P2’s caregiver or caregivers in carrying out the service plan. Repeat Violation: You were cited for a similar violation in a Correction Order issued on February 14, 2019. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For five participants whose records were reviewed (P1, P2, P3, P4, and P5), the license holder did not develop a written plan of care as required. a. The license holder failed to develop written plans of care for P1, P3, P4, and P5 that included§: · an update of the preliminary service plan and additional services required by the participant; and · provisions for quarterly review and quarterly revisions of the individual plan of care. b. The license holder failed to develop a written plan of care for P2 within 90 days of P2’s admission to the center. P2 was admitted to the center on December 16, 2020 and the license holder developed a written plan of care for P2 on April 14, 2021. Additionally, the license holder failed to develop a written plan of care for P2 that included§: · an update of the preliminary service plan and additional services required by P2; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Repeat Violation: You were cited for a similar violation in a Correction Order issued on February 14, 2019. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1, P2, P3, P4, and P5 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 9555.9650, item A. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of annual performance evaluations in SP1’s personnel record. Although the license holder maintain documentation in SP1’s personnel record that performance evaluations were completed, the performance evaluations were not dated; therefore, it was unable to be determined whether the performance evaluations were completed annually. Repeat Violation: You were cited for a similar violation in a Correction Order issued on February 14, 2019. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Rules, part 9555.9690, subpart 1, item A. Violation: The license holder did not maintain staff ratio as required. The license holder failed to maintain a minimum staff to participant ratio of one staff member present for every eight participants present. Upon the licensor’s arrival to the center on December 7, 2022 at 8:20am, there were seventeen participants present with only one staff person present. Two additional staff persons arrived to the center at 8:28am. Corrective Action Ordered: Immediately, you must maintain a minimum staff to participant ratio as required in Minnesota Rules, part 9555.9690, subpart 1. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish a program abuse prevention plan (PAPP) as required. The license holder failed to establish a written PAPP that included an assessment of the physical plant where the licensed services were provided, including the condition and design of the building as it related to the safety of the participants. The license holder’s PAPP stated the center was located in a “one story commercial building”; however, the center was located in the lower level of a two story commercial building. Corrective Action Ordered: Within 30 days of receiving this order, you must establish a PAPP that includes an accurate assessment of the physical plan where licensed services are provided. 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: Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit P.O. Box 64953 Saint 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 me as soon as possible. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6591
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