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April 21, 2023 Abdulkadir Awale, Authorized Agent Bashi Adult Daycare Inc 1501 Riverwood Drive Suite 160 Burnsville, Minnesota 55337 License Number: 1110638 (Rule 223) CORRECTION ORDER Dear Abdulkadir Awale: On April 13, 2023, a licensing review of Bashi Adult Daycare Inc, located at 1501 Riverwood Drive Suite 160, Burnsville, 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 two of three 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 IAPPs for P1 and P2 as part of P1 and P2’s initial individual program plan or service plan. The license holder maintained IAPPs for P1 and P2 that were not dated; therefore, the date the IAPPs were developed was unable to be determined. b. The license holder failed to review P1’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained an IAPP for P1 that was not dated; therefore, it was unable to be determined whether reviews of P1’s IAPP were completed. Corrective Action Ordered: Within 30 days of receiving this order, you must review P1’s IAPP with P1 and P1’s interdisciplinary teams and document the review. On an ongoing basis, you must maintain compliance as required in this subpart. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not include information in the participant’s written record as required. The license holder failed to include the following information in P1, P2, and P3’s participant record: · an application form that included the name and telephone number of the participant’s physician or medical provider; and · attendance and participation reports and progress notes that were recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1, P2, and P3’s application form to include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P3), the license holder did not develop a written plan of care as required.
The license holder failed to develop a written plan of care for P3 that included provisions for quarterly review and quarterly revision of the individual plan of care. Corrective Action Ordered: Within 30 days of receiving this order, you must review P3’s written plan of care with P3 and revise the plan of care, if necessary. On an ongoing basis, you must maintain compliance as written in this subpart. 4. 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 an annual performance evaluation in SP1’s personnel record. 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 SP1’s personnel record. On an ongoing basis, you must maintain compliance as required in this item. 5. 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 dietician met any licensure, registration, or certification requirements required to perform services. The license holder maintained documentation that the registered dietician’s license expired August 31, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation that your registered dietician meets 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. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP2 orientation to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact. Corrective Action Ordered: Immediately, you must provide the required orientation training detailed above to SP2. Within 30 days of receiving this order, you must: · complete an audit of all personnel records to ensure all staff persons have received the required orientation training detailed above; and · for staff persons that have not received the required orientation training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9555.9690, subpart 3.
Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least 4 hours of supervised orientation before the employee worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the required orientation training detailed above to SP2 and document the completed training in SP2’s record; · complete an audit of all personnel records to ensure all staff persons have received the required orientation training detailed above; and · for staff persons that have not received the required orientation training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 a minimum of eight hours of in-service training annually in areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 training in the areas detailed above and document the completed training in the SP1’s record; · complete an audit of all personnel records to ensure all staff persons have received the required annual in-service training detailed above; and · for staff persons that have not received the required annual in-service training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9690, subpart 2, item C. Violation: The license holder did not provide staff coverage of the center as required. The license holder failed to have a person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times in the center when participants were present. Corrective Action Ordered: Immediately, you must have a person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times in the center when participants were present. On an ongoing basis, you must maintain compliance as required in this subpart. 10. 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. b. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly in 2022. The license holder maintained documentation that a review of the exercise program was conducted on March 14, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must ensure your registered nurse provides consultation and review of your health services. On an ongoing basis, you must maintain compliance as required in these subparts. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish and enforce their program abuse prevention plan (PAPP) as required. The license holder failed to ensure the license holder’s governing body or the governing body’s delegated representative reviewed the PAPP at least annually, using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. The license holder maintained documentation that the PAPP was most recently reviewed in July 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must review your PAPP using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. 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: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. 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, Supervisor Licensing Division Office of Inspector General
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