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April 19, 2023
Asha Hibad, Authorized Agent Somali Seniors Center 2733 Park Avenue Minneapolis, Minnesota 55407 License Number: 1056588 (Rule 223) CORRECTION ORDER Dear Asha Hibad: On April 12, 2023, a licensing review of Somali Seniors Center, located at 2733 Park Avenue, 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 three 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 P2 orientation to the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. P2 was admitted to the program on January 17, 2023; however, the license holder failed to provide P2 the required orientation until March 30, 2023. Repeat Violation: In a Correction Order that DHS issued March 21, 2022, you were cited for a similar violation Corrective Action Ordered: On an ongoing basis, you maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one participant whose record was reviewed (P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder failed to review P3’s IAPP quarterly. The license holder maintained documentation that P3’s IAPP was most recently reviewed November 29, 2022. Repeat Violation: In a Correction Order that DHS issued March 21, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must review P3’s IAPP with P3’s interdisciplinary team and document the review. 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 and procedures to participants and their caregivers upon admission as required.
The license holder failed to distribute policies and procedures to P2 upon admission. P2 was admitted on January 17, 2023. The license holder distributed policies and procedures to P2 on March 30, 2023. Repeat Violation: In a Correction Order that DHS issued on March 21, 2022, you were cited for a similar violation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in the part. 4. Citation: Minnesota Rules, part 9555.9660. Violation: For two participants whose records were reviewed (P2, and P3), 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 P2’s participant record: · an application form signed by P2 or P2’s caregiver that included the name and telephone number of a secondary person to call in case of an emergency involving P2; · a medical report dated within the three months prior to or 30 calendar 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 the participant; o a release signed by the physician indicating whether the participant may engage in a structured exercise program; and o documentation that the participant is free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · notes on special problems or on changes needed in medication and on the need for medication assistance. b. The license holder failed to include the following information in P3’s participant record: · an application form signed by P3 or P3's caregiver that included the name and telephone number of P3’s physical or medical provider; and · a medical report that included a report on a physical examination, updated annually. The license holder most recently maintained documentation of a report on P3’s physical examination dated October 21, 2021. Repeat Violation: In a Correction Order that DHS issued on March 21, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P2 and P3’s participant records. 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. P1’s admission date was April 4, 2022. The license holder failed to: · conduct a needs assessment for P1 that addressed P1’s physical status determined from the medical report received from P1’s physician. The license holder conducted a needs assessment for P1 on April 4, 2022 but did not maintain a medical record from P1’s physician until April 22, 2022; and · develop a preliminary service plan for P1 within 30 days of P1’s admission. The license holder maintained a preliminary service plan that was not dated; therefore, the date the preliminary service plan was developed was unable to be determined. Additionally, the license holder failed to develop a preliminary service plan for P1 that included: o scheduled days of P1’s attendance at the center; o P1’s nutritional needs and dietary restrictions. P1’s medical report stated P1 has a “low saturated fats, low cholesterol, low sodium, low carb” diet; however, this information was not included in P1’s preliminary service plan; and o services and activities in which P1 would take part immediately upon admission. b. The license holder failed to conduct a needs assessment for P2 within 30 days of P2’s admission. The license holder maintained a needs assessment for P2 that was not dated; therefore, the date the needs assessment was conducted was unable to be determined. Additionally, the license holder failed to conduct a needs assessment for P2 that included P2’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P2’s physician. Repeat Violation: In a Correction Order that DHS issued on March 21, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct a needs assessment for P1 and P2 that includes the information detailed above; · update P1’s preliminary service plan to include the information detailed above; · complete an audit of all participants’ needs assessments and preliminary service plans to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 2 are maintained; and · for participants who do not have needs assessments and 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. 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 P3), 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 short and long term objectives for the participant stated in concrete, measurable and time specific outcomes. b. 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. Repeat Violation: In a Correction Order that DHS issued on March 21, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a written plan of care for P1 that includes the information listed above; · review P3’s written plan of care with P3 and revise the plan of care, if necessary; · 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 9555.9690, subpart 4. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 and SP2 in-service training annually in the following areas in 2023: · areas related to care of center participants, including provision of medication assistance and review of parts 9555.8000 to 9555.8500, 9555.9600 to 9555.9730; and · Minnesota Statutes, section 626.557. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 the training detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 8. 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 most recently documented a review of the PAPP on March 10, 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. 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 regarding this Correction Order, please contact your licensor, Desiree Tiller, at 651-431-4622. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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