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January 31, 2023 Abdurahim Buse, Authorized Agent Sunshine Adult Day Care Center 775 Milton Street North St. Paul, Minnesota 55104 License Number: 1082009 (Rule 223) NOTICE OF NON-COMPLIANCE AND CORRECTION ORDER Dear Abdurahim Buse: On October 13, 2022, as a result of a licensing review, a Correction Order was issued to Sunshine Adult Day Care Center, located at 775 Milton Street North, St. Paul, Minnesota. You were ordered to take corrective action for violations determined under citations 1, 3, 5, 6, 7, 8, 9, 10, 11 and 12. On January 12, 2023, a follow-up licensing review was conducted to determine that correction action was achieved. For citations 3, 5, 6, 7, 8, 9, 10 and 12 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 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. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. Although the license holder maintained an IAPP for P1, the IAPP was not dated; therefore, it was unable to determine if the license holder developed an IAPP for P1 as part of P1’s initial individual program plan or service plan and reviewed P1’s IAPP quarterly as part of the review of the program plan or service plan. b. The license holder failed to develop an IAPP for P2 as part of P2’s initial individual program plan or service plan. Corrective Action Ordered: Immediately, you must develop an IAPP for P2. 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. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. License Holder Response: The license holder developed an IAPP for P2. DHS Response: The license holder failed to review P1 and P2’s IAPPs with the person’s interdisciplinary team. Corrective Action Ordered: Within 15 days of receiving this order, you must review P1 and P2’s IAPPs with the person’s interdisciplinary team and document the review within the person’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Rules, part 9555.9660, subpart 1. 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. a. The license holder failed to include the following information in P1’s record: · an application form signed by P1 or P1’s caregiver that included P1's living arrangement and source of referral; · a medical report, dated within the three months prior to or 30 days after P1’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 P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · P1's service agreement with the center that specified the responsibilities of P1 and the center with respect to payment for and provision of services and was signed by P1 or P1's caregiver and the center director; · participation reports and progress notes that were recorded at least monthly; and · a statement signed by P1 specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. b. The license holder failed to include the following information in P2’s record: · a medical report 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 in 2022; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · 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; · participation reports and progress notes that were recorded at least monthly; 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. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’s participant record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. License Holder Response: The license holder maintained an application form signed by P1 and P1’s caregiver that included P1's living arrangement and source of referral.
DHS Response: The license holder failed to maintain the following information in P1’s record: · a medical report 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 P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · P1's service agreement with the center that specified the responsibilities of P1 and the center with respect to payment for and provision of services and was signed by P1 or P1's caregiver and the center director; · participation reports and progress notes that were recorded at least monthly; and · a statement signed by P1 specifying the basis on which P1 was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. Additionally, the license holder failed to maintain the following information in P2’s record: · a medical report 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 in 2022; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · 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; · participation reports and progress notes that were recorded at least monthly; 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. Corrective Action Ordered: Within 15 days of receiving this order, you must maintain all required information detailed above in P1 and P2’s record. On an ongoing basis, you must maintain compliance as required in this subpart. 6. 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 develop a preliminary service plan for P1 that included P1’s nutritional needs and, where applicable, dietary restrictions. b. The license holder failed to develop a preliminary service plan for P2 that included the following information and specifications: · transportation arrangements for getting P2 to and from the center; · P2’s nutritional needs and, where applicable, dietary restrictions; and · role of P2’s caregiver or caregivers in carrying out the service plan. 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; · complete an audit of all participants’ preliminary service plans to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 2 are maintained; and · for participants who do not have preliminary service plans that include all requirements, you must develop a plan detailing how your program will maintain a complete needs assessment within 60 calendar days of receiving this order. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. License Holder Response: The license holder updated P2’s preliminary service plan as ordered. DHS Response: The license holder failed to update P1’s preliminary service plan to include P1’s nutritional needs and, where applicable, dietary restrictions. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s prelimary service plan to include P1’s nutritional needs and, where applicable, dietary restrictions. On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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. a. The license holder failed to develop a written plan of care for P1 that included§: · an update of the preliminary service plan and additional services required by P1; · short and long term objectives for P1 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · the anticipated duration of the individual plan of care as written. b. The license holder failed to develop written plans of care for P2 that included§: · an update of the preliminary service plan and additional services required by P2; · short and long term objectives for P2 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; 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. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. License Holder Response: The license holder developed a written plan of care for P2 as ordered. DHS Response: The license holder failed to develop a written plan of care for P1 that included: · an update of the preliminary service plan and additional services required by P1; · short and long term objectives for P1 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; and · the anticipated duration of the individual plan of care as written. Corrective Action Ordered: Within 15 days of receiving this order, you must develop a written plan of care for P1 that includes 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 one of two staff persons whose records were reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation of an annual performance evaluation in SP1’s personnel record in 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a performance evaluation for SP1 and maintain documentation of the evaluation in the SP1’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 complete corrective action as ordered. DHS Response: The license holder failed to maintain documentation of an annual performance evaluation in SP1’s record. Corrective Action Ordered: Within 15 days of receiving this order, you must complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 9. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For three consultants whose record were reviewed, the license holder did not include all required information in the personnel record. The license holder failed to maintain the following in the registered dietician, registered nurse and physical therapist’s personnel records: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. 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 dietician, registered nurse and physical therapist specifying conditions and terms of employment; and · maintain documentation that your registered dietician, registered nurse, and physical therapist meet licensure, registration, and certification requirements required to perform the services specified in the contract. 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 maintained the following in the registered nurse’s personnel record: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. DHS Response: The license holder failed to maintain the following in the registered dietician and physical therapist’s personnel records: · a copy of a signed contract or letter of appointment specifying conditions and terms of employment; and · documentation that the consultant met any licensure, registration, or certification requirements required to perform services. 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 dietician and physical therapist specifying conditions and terms of employment; and · maintain documentation that your registered dietician and physical therapist meet licensure, registration, and certification requirements required to perform the services specified in the contract. On an ongoing basis, you must maintain compliance as required in this item. 10. Citation: Minnesota Rules, part 9555.9710 subparts 1, 3, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to offer a midmorning and midafternoon snack. b. The license holder failed to maintain a record indicating the menu for all meals served for at least six months. Additionally, the license holder failed to maintain menus for all meals and snacks approved by a registered dietician. c. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly. d. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. e. The license holder failed to maintain a family and social history in P2’s record. Corrective Action Ordered: Immediately, you must offer a midmorning and midafternoon snack. Within 30 days of receiving this order, you must: · ensure your registered dietician approves your menus for all meals and snacks; · have your registered nurse provide consultation and review of your health services; · have your physical therapist provide consultation and review of your exercise program; and · maintain a family and social history in P2’s record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. License Holder Response: The license holder ensured a registered nurse provided consultation and review of the health services at least monthly. DHS Response: The license holder failed to: · offer a midmorning and midafternoon snack; · maintain menus for all meals and snacks approved by a registered dietician; · ensure a physical therapist provided consultation and review of the exercise program at least quarterly; and · maintain a family and social history in P2’s record. Corrective Action Ordered: Immediately, you must offer a midmorning and midafternoon snack. Within 15 days of receiving this order, you must: · maintain menus for all meals and snacks approved by a registered dietician; · ensure your physical therapist provides consultation and review of your exercise program; and · maintain a family and social history in P2’s record. On an ongoing basis, you must maintain compliance as required in this part. 12. 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 failed to establish a policy and procedures related to suspected or alleged maltreatment that: · identified 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; and · identified the secondary person or position who will ensure that, when required, internal reviews are completed. The license holder’s policy identified “Staff” as the primary position and “Sunshine ADC director” as the secondary person, however, these positions were both held by the authorized agent and the authorized agent stated the center did not have staff at the time of the licensing review. Corrective Action Ordered: Immediately, you must establish policies and procedure related to suspected or alleged maltreatment that: · identifies 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; and · identifies the secondary person or position who will ensure that, when required, internal reviews are completed. Additionally, you must post a copy of the internal and external reporting policies and procedures in a prominent location I the program. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. License Holder Response: The license holder did not complete corrective action as ordered. DHS Response: The license holder failed to establish and enforce a policy and procedures related to suspected or alleged maltreatment that identified 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; and · who will ensure that, when required, internal reviews are completed. 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. 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, 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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