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February 3, 2023 Mohamed Keynan, Authorized Agent Cedar Adult Day Care Services Center 410 Cedar Avenue South Minneapolis, Minnesota 55454 License Number: 1097782 (Rule 223) CORRECTION ORDER Dear Mohamed Keynan: On January 18, 2023, a licensing review of Cedar Adult Day Care Services Center, located at 415 Cedar 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 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For one of two participants whose record was reviewed (P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan (PAPP) as required. The license holder failed to provide orientation to P2 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission. P2 was admitted to the center on September 6, 2022 and the license holder provided P2 the required orientation on September 19, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. 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. The license holder failed to develop an IAPP for P1 as part of P1’s initial individual program plan or service plan. b. The license holder maintained an IAPP for P2 that was not dated; therefore, it was unable to be determined if the license holder developed P2’s IAPP as part of the initial individual program plan or service plan or reviewed P2’s IAPP quarterly. Corrective Action Ordered: Immediately, you must develop an IAPP for P1. 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. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P2), the license holder did not distribute policies, program information, and participants’ rights to participants upon admission as required. P2’s admission date was September 6, 2022. The license holder failed to distribute policies, program information, and participants’ rights to P2 upon admission. The license holder provided P2 policies, program information, and participants’ rights on September 19, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this part. 4. 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 that included P1's source of referral and the name and telephone number of P1's physician or medical provider; · a medical report dated within the three months prior to or 30 days after P1’s admission to the center. P1’s admission date was March 1, 2022 and the license holder maintained a medical report for P1 on January 11, 2023. Additionally, the license holder failed to maintain a medical report for P1 that included a report on a physical examination; and · participation reports and progress notes that are recorded at least monthly. b. The license holder failed to include the following information in P2’s record: · an application form that included P2's source of referral and the name and telephone number of P2's physician or medical provider; · 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; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; 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; · participation reports and progress notes that are recorded at least monthly; · notes on special problems or on changes needed in medication and on the 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. P2’s admission date was September 6, 2022 and the license holder maintained the required statement on September 19, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 5. 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 from the medical report received from P1's physician. The license holder completed P1’s needs assessment on March 7, 2022; however, the license holder did not maintain a medical report for P1 until January 11, 2023. b. The license holder failed to conduct a needs assessment for P2 that included: · §P2's functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · §P2's physical status, determined by observation, from the intake screening interview, and from the medical report received from P2's physician. c. The license holder failed to develop a preliminary service plan for P1 that included P1’s accurate nutritional needs and dietary restrictions. The license holder documented in P1’s preliminary service plan that P1 had no nutritional needs; however, P1’s medical report indicated P1 had a low carbohydrate and low salt diet. d. The license holder failed to develop a preliminary service plan for P2 that included transportation arrangements for getting P2 to and from the center. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1 and P2’s needs assessments to include the information detailed above; and · update P1 and P2’s preliminary service plans to include the information and specifications detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 6. 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; and · the anticipated duration of the individual plan of care as written. b. 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; · short and long term objectives for P2 stated in concrete, measurable and time specific outcomes; · 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. On an ongoing basis, you must maintain compliance as required in this subpart. 7. 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 documentation that the registered nurse met licensure requirements required to perform services. The license holder maintained a license for the registered nurse that expired on January 31, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation that your registered nurse meets licensure requirements required to perform the services specified in the contract. On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not provide training to a mandated reporter as required. The license holder failed to provide SP1 annual review of the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. The license holder most recently provided SP1 the required annual review on October 17, 2021. Corrective Action Ordered: Immediately, you must provide the required training detailed above to SP1. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Rules, part 9555.9710, subparts 3 and 4. Violation: The license holder did not offer services as required. a. The license holder failed to offer health services, and ensure a registered nurse provided consultation and review of the health services at least monthly prior to January 2, 2023. b. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must have your exercise program reviewed by a registered physical therapist. On an ongoing basis, you must maintain compliance as required in these subparts. 10. Citation: Minnesota Rules, part 9555.9720, subpart 1. Violation: The license holder did not ensure safety requirements as required. The license holder failed to include a thermometer in their first aid kit. Corrective Action Ordered: Immediately, you must maintain a thermometer in your first aid kit. On an ongoing basis, you must maintain compliance as required in this subpart. 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, 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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