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April 25, 2023 Abdulkadir Warsame, Authorized Agent Metro Adult Day Care LLC 919 12th Avenue SE # 401 Minneapolis, Minnesota 55414 License Number: 1110200 (Rule 223) CORRECTION ORDER Dear Abdulkadir Warsame: On March 22, 2023, a licensing review of Metro Adult Day Care LLC, located at 1821 University Avenue West, St. Paul, 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.02, subdivision 2a. Violation: The license holder failed to provide adult day services as required. "Adult day care," "adult day services," and "family adult day services" mean a program operating less than 24 hours per day that provides functionally impaired adults with an individualized and coordinated set of services including health services, social services, and nutritional services that are directed at maintaining or improving the participants' capabilities for self-care. Adult day care, adult day services, and family adult day services do not include programs where adults gather or congregate primarily for purposes of socialization, education, supervision, caregiver respite, religious expression, exercise, or nutritious meals. During the licensing review on March 22, 2023, the license holder informed DHS that the center was providing adult day services to 51 participants; however, of those 51 participants the license holder stated 45 participants were admitted between March 15, 2023 and March 22, 2023. When asked by DHS what prompted such a significant increase in participant attendance, the license holder stated it was due to the participants’ request for support with religious practices and observances. Because the newly admitted participants gathered or congregated primarily for the purpose of religious expression, the license holder failed to comply with the definition of “adult day services,” as required by this subdivision. Correction Action Ordered: Immediately, you must ensure you are not providing adult day services primarily for the purpose of practicing religious expression. On an ongoing basis, you must maintain compliance as written in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For three of three participants whose records were reviewed (P1, P2, and P3), 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 P1, P2, and P3 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission. · P1 was admitted to the center on May 2, 2022. The license holder provided P1 the required orientation on May 6, 2022. · P2 was admitted to the center on August 1, 2022. The license holder provided P2 the required orientation on August 8, 2022. Corrective Action Ordered: Immediately, you must: · provide an orientation to P3 on your internal and external reporting procedures and PAPP; and · document that P3 was provided the orientation in P3’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. Although the license holder developed an IAPP for P3, the license holder failed to ensure P3’s IAPP contained an individualized assessment of P3’s susceptibility to sexual and physical abuse. b. The license holder failed to review P1 and P2’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained documentation that P1’s IAPP was most recently reviewed May 6, 2022. · The license holder maintained documentation that P2’s IAPP was most recently reviewed November 7, 2022. Corrective Action Ordered: Immediately, you must update P3’s IAPP to include an individualized assessment of P3’s susceptibility to sexual and physical abuse. 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. 4. Citation: Minnesota Rules, part 9555.9640 Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not distribute participants’ rights, policies, and program information to participants upon admission as required. a. The license holder failed to distribute participants’ rights, policies, and program information to P1 and P2 upon admission. · P1 was admitted to the center on May 2, 2022 and the license holder distributed participants’ rights, policies, and program information to P1 on May 6, 2022. · P2 was admitted to the center on August 1, 2022 and the license holder distributed participants’ rights, policies, and program information to P2 on August 8, 2022. b. P3’s admission date was March 8, 2023. The license holder failed to distribute the following policies and procedures to P3 and P3’s caregivers: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. Corrective Action Ordered: Immediately, you must: · distribute the policies and procedures and participants’ rights listed above to P3 and their caregivers; and · document the distribution of the policies and procedures and participants’ rights in P3’s record. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records that evaluates if your policies and procedures and participants’ rights were provided to the participant; and · for participants who did not receive your policies and procedures or participants’ rights, you must develop a plan detailing how your program will distribute the policies and procedures and participants’ rights to the participant and their caregiver 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 part. 5. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. Violation: For one participant whose record was reviewed (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 P3’s record: · P3's service agreement with the center that specified the responsibilities of P3 and the center with respect to payment for and provision of services and was signed by P3 and the center director; · attendance and participation noted that were recorded at least monthly; and · a statement signed by the center director and P3 at the time of P3's admission specifying the basis on which P3 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 P3’s participant record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 6. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P1 and P3), 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 the participant’s physical status, determined by observation, from the intake screening interview, and from the medical report received from the participant’s physician. The license holder conducted a needs assessment for P1 on May 5, 2022; however, the license holder did not maintain a medical report for P1 until June 7, 2022. b. Although the license holder maintained a needs assessment in P3’s record, the license holder failed to document the date the needs assessment was conducted; therefore, it could not be determined if P3’s needs assessment was conducted within 30 days of P3’s admission to the center. Corrective Action Ordered: Within 30 days of receiving this order, you must update P1’s needs assessment to include the participant’s physical status based on information received from the participant’s medical report. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. The license holder failed to provide a midafternoon snack. Corrective Action Ordered: Immediately, you must provide a midafternoon snack. Compliance with this order will be reviewed onsite. 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 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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