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January 19, 2023 Ismail Yusuf, Authorized Agent Whittier Senior Center Inc. 2630 Nicollet Avenue Minneapolis, Minnesota 55408 RE: Request for Reconsideration of Correction Order License Number: 1093044 (Rule 223) Dear Ismail Yusuf: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of three of five citations that DHS issued to you in a Correction Order dated May 9, 2022 (Attachment A). The license holder did not challenge the remaining two citations that were cited in the Correction Order. SUMMARY OF CITATIONS AND RECONSIDERATION DETERMINATION: Citation # 2: DHS issued Citation # 2 because it determined that the license holder failed to document the review of P2’s individual abuse prevention plan (IAPP) with P2’s interdisciplinary team at least annually. Although the license holder reviewed P2’s IAPP quarterly, the license holder most recently reviewed P2’s IAPP with P2’s interdisciplinary team in November 2019. Your Response: The license holder stated that P2 admitted to the center in March 2022 and P2’s IAPP was signed by P2 on March 7, 2022. The license holder submitted a copy of the IAPP. Applicable Law: Minnesota Statutes, section 245A.65, subdivision 2(b), requires the license holder to document the review of the IAPP of a person receiving services by the interdisciplinary team at least annually.
Reconsideration Determination: The ID key that was provided to the license holder with the May 9, 2022 correction order incorrectly identified P2 and P3. Although the correction order refers to P2 for this citation, the ID Key incorrectly reversed the identities of P2 and P3. As a result, DHS is including an Amended ID Key with this letter that correctly identifies P2 and P3. The license holder documented that the center’s authorized agent reviewed the IAPP for P2, who is identified in the Amended ID Key, on a quarterly basis. However, the license holder did not document that P2’s IAPP was reviewed at least annually by P2’s interdisciplinary team, as required by Minnesota Statutes, section 245A.65, subdivision 2(b). Therefore, this citation was correct and it is affirmed. Because the identity of P2 was incorrectly identified in the ID Key that was issued at the time of the May 9, 2022 correction order, the license holder may submit a new request for reconsideration of this citation if it believes the citation is incorrect after reviewing this letter and the Amended ID Key. Citation # 3: DHS issued Citation # 3 because it determined that the license holder failed to include an application form in P3’s participant record that included the name and telephone number of the secondary person to call in case of an emergency involving P3. Your Response: The license holder stated that P3 does not have a second emergency contact because P3 exercised their right to refuse to include another person as an emergency contact. The license holder stated that it has since included that information in the space provided to document a second contact person. Applicable Law: Minnesota Rules, part 9555.9660, subpart 1, requires that the license holder develop and maintain a written record for each participant. The written record shall include an application form signed by the participant or the participant’s caregiver that includes the name and telephone number of the person to call in case of an emergency involving the participant and the name and number of another person to call if that person cannot be reached. Minn. R. 9555.9660, subpart 1, item A(2).
Reconsideration Determination: As described above, the ID key that was provided to the license holder with the May 9, 2022 correction order incorrectly identified P2 and P3. Although the correction order refers to P3 for this citation, the ID Key incorrectly reversed the identities of P2 and P3. As a result, DHS is including an Amended ID Key with this letter that correctly identifies P2 and P3. At the time of the licensing review, the participant record for P3 (as identified in the Amended ID Key), did not include any information for a second emergency contact, as required by Minnesota Rules, part 9555.9660, subpart 1. Instead, the space for the second emergency contact on the application form was blank. In the license holder’s request for reconsideration, the license holder stated that it has since noted in the participant record if a participant declines to provide a second emergency contact. However, the documentation at the time of the licensing review did not demonstrate that the program requested P3’s second emergency contact information and that P3 declined to provide it. Therefore, this citation was correct and it is affirmed. Because the identity of P3 was incorrectly identified in the ID Key that was issued at the time of the May 9, 2022 correction order, the license holder may submit a new request for reconsideration of this citation if it believes the citation is incorrect after reviewing this letter and the Amended ID Key. Citation # 5: DHS issued Citation # 5 because it determined that the license holder failed to ensure that refrigeration had a temperature of 40 degrees Fahrenheit or less. At the time of the licensing review, DHS licensors observed the refrigerator to have a temperature of 45 degrees Fahrenheit. Your Response: The license holder stated that the DHS licensor checked the refrigerator temperature during the lunch hour, when the refrigerator was opened frequently. The license holder stated that approximately 30% of cool air is temporarily lost when a refrigerator is opened. The license holder stated that it consistently keeps the temperature of the refrigerator at below 40 degrees and the refrigerator has both an internal thermometer and an exterior digital read-out for monitoring. Applicable Law: Minnesota Rules, part 9555.9710, subpart 1, item B, states that the center shall provide refrigeration for dairy products and other perishable foods. The refrigeration must have a temperature of 40 degrees Fahrenheit or less.
Reconsideration Determination: Under Minnesota Rules, part 9555.9710, subpart 1, item B, the center’s refrigerator is required to have a temperature of 40 degrees Fahrenheit or less. The DHS licensors observed and documented that the facility’s refrigerator had a temperature of 45 degrees Fahrenheit at the time of the licensing review, which the license holder does not appear to dispute. Therefore, this citation was correct. Disposition: The Commissioner has reviewed the relevant laws and all of the information you submitted in response to the Correction Order. The evidence supports Citations # 2, 3, and 5. Therefore, they are affirmed. The other two citations in the Correction Order, Citations #1 and 4, which the license holder did not challenge, are also affirmed. This is a final agency decision. However, because the identities of P2 and P3 were incorrectly identified in the ID Key that was issued at the time of the May 9, 2022 correction order, the license holder may submit a new request for reconsideration of Citations #2 and 3 if it believes the citations are incorrect after reviewing this letter and the Amended ID Key. The Commissioner appreciates your response and encourages you to continue to work cooperatively with your licensor to ensure the safety and well-being of the individuals you serve. Sincerely,
Morgan Bianco, Attorney Legal Counsel’s Office Office of Inspector General
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