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May 1, 2023 Mohamud Mohamud, Authorized Agent Minnehaha Adult Day Services LLC 4549 124th Court Northeast Blaine, Minnesota 55449 License Number: 1082876 (Rule 223) CORRECTION ORDER Dear Mohamud Mohamud: On April 13, 2023, a licensing review of Minnehaha Adult Day Services LLC, located at 3950 Minnehaha 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 three of six participants whose records were reviewed (P4-P6), 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 P4-P6 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Required: Immediately, you must: · provide an orientation to P4-P6 on your internal and external reporting procedures and PAPP; and · document that P4-P6 were provided orientation in P4-P6’s records. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records for orientation on your internal and external reporting procedures and PAPP; and · for participants that have not received the required orientations, you must develop a plan detailing how the orientation will be provided 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 these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For six participants whose records were reviewed (P1-P6), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop IAPPs for P4-P6 as part of the participant’s initial individual program plan or service plan. As of the date of the licensing review on April 13, 2023, the license holder had not developed IAPPs for P4-P6. b. The license holder failed to review P1-P3’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 on March 10, 2021. · The license holder maintained documentation that P2’s IAPP was most recently reviewed on February 1, 2021. · The license holder maintained documentation that P3’s IAPP was most recently reviewed on July 1, 2020. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Ordered: Immediately, you must develop IAPPs for P4-P6. Within 30 days of receiving this order, you must: · review P1, P2, and P3’s IAPPs with the person and their 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. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For three participants whose records were reviewed (P4-P6), the license holder did not distribute policies and procedures to participants and their caregivers upon admission as required. a. The license holder failed to distribute the following policies and procedures to P4-P6 upon admission: · 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. b. The license holder failed to distribute the participant’s rights to P4-P6 upon admission. Corrective Action Ordered: Immediately, you must: · distribute the policies and program information and participants’ rights detailed above to P4-P6; and · document the distribution of the policies and program information and participants’ rights in the participant’s record. Within 30 days of receiving this order, you must: · complete an audit of all participants’ records that evaluates if your policies and program information and participants’ rights were provided to the participant; and · for participants who did not receive your policies and program information or participants’ rights, you must develop a plan detailing how your program will distribute the policies and program information 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. 4. Citation: Minnesota Rules, part 9555.9660, subparts 1 and 3. Violation: For six participant’s whose records were reviewed (P1-P6), 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: · a medical report that included a physical examination, updated annually. The most recent report on a physical examination that the license holder maintained for P1 was dated March 7, 2022; and · participation reports and progress notes that were recorded at least monthly in P1’s record. b. The license holder failed to include the following information in P2’s record: · a medical report that included: o a report on physical examination, updated annually; o a medical history of P2; and o documentation that P2 was free from communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would otherwise endanger the health of other participants; and · participation reports and progress notes that were recorded at least monthly. c. The license holder failed to include the following information in P3’s record: · a medical report that included a physical examination, updated annually. The most recent report on a physical examination that the license holder maintained for P3 was dated March 15, 2021; and · participation reports and progress notes that were recorded at least monthly. d. The license holder failed to include the following information in P4 and P5’s record: · the person’s service agreement with the center, that specified the responsibilities of the person and the center with respect to payment for and provision of services and signed by the person or the person’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 person at the time of admission specifying the basis on which the person was determined to be capable or incapable of taking appropriate action for self-preservation under emergency conditions. e. The license holder failed to include the following information in P6’s record: · a medical report that included a report on a physical examination; · P6’s service agreement with the center, that specified the responsibilities of P6 and the center with respect to payment for and provision of services and signed by P6 or P6’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 P6 at the time of admission specifying the basis on which P6 was determined to be capable or incapable of taking appropriate action for self-preservation under emergency conditions. f. The license holder failed to provide P4-P6 with written notice that ensured the participant or their guardians had been informed of the participant’s rights to contest the accuracy and completeness of the data maintained in the record. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1-P6’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 5. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P4-P6), the license holder did not complete initial service planning as required. a. The license holder failed to conduct needs assessments for P4-P6 within 30 days of admission that addressed: · the participant’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · the participant's functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · the participant's physical status, to be determined by observation, from the intake screening interview, and from the medical report received from the participant's physician. b. The license holder failed to develop preliminary service plans for P4-P6 within 30 days of admission that included: · scheduled days of the participant’s attendance at the center; · transportation arrangements for getting the participant to and from the center; · the participant’s nutritional needs and, where applicable, dietary restrictions; · role of the participant’s caregiver or caregivers in carrying out the service plan; and · services and activities in which the participant would take part immediately upon admission. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P4-P6 as detailed above; · develop preliminary service plans for P4-P6 that include the information and specifications 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. 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 9555.9700, subpart 3. Violation: For six participants whose records were reviewed (P1-P6), the license holder did not develop a written plan of care as required. a. The license holder failed to develop written plans of care for P1-P3 that included provisions for quarterly review and quarterly revision of the individual plan of care. b. The license holder failed to, within 90 days of P4-P6’s admission to the center, develop written plans of care for P4-P6 by the center staff with the participant, the participant’s caregiver, and other agencies or individual service providers, including: · an update of the preliminary service plan required in subpart 2 and additional services required by the participant; · short and long-term objectives for the participant 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 revision of the individual plan of care. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P4-P6 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. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, 4, 6, and 7 Violation: The license holder did not offer services as required. a. The license holder failed to serve a meal to participants that were at the center for more than 4 ½ hours. Although the license holder maintained a menu that reflected breakfast, midmorning snack, lunch and mid-afternoon snack, the center director stated participants were not being offered meals on the day of the licensing review; therefore, food service was not provided as required. b. The license holder failed to offer health services as required. The license holder failed to ensure a registered nurse provided consultation and review of the health services prior to January 2023. Additionally, the license holder failed to ensure health services included: · monitoring a person’s health status and reporting changes to the person’s caregiver, physician, and center director; · educating and counseling persons on good health practices · maintaining a listing of professional health resources available for referrals as needed by people; · developing policies and monitoring procedures for participant self-administration of medications for training unlicensed personnel who provide medication assistance; and · supervising staff distribution of medication and assistance with a person’s self-administration of medication and ensuring compliance with 9555.9680, subpart 2, item C. c. The license holder failed to ensure the registered physical therapist provided consultation and review of the exercise program at least quarterly. Reviews were not conducted between March 2021 and October 2022. d. The license holder failed to follow the monthly plan for diversified daily program activities. The license holder provided an activity calendar that listed the following information: · 7:00 – 8:00AM Current News & Social · 8:00 – 9:00AM Breakfast/Morning Snack · 9:00 – 10:00AM Exercise and Strength Training · 10:00 – 11:00AM Lunch · 11:00 – 12:00AM Activities & Games · 12:00 – 1:00PM Afternoon Snack · 1:00 – 1:30PM Rest Time · 1:30 – 2:00PM Departure However, DHS licensors observed the following: · 9:30AM-10:00AM: o eight participants playing cards; · 10:00AM-10:35AM: o five participants lying down sleeping; o eight participants sitting on couches or chairs on their cell phones or other hand-held electronic devices; and o several other participants socializing amongst themselves with little interaction from staff for significant periods of time; and · 10:35AM-11:00AM: o no staff observed facilitating activities. Additionally, the license holder’s daily activity calendar reflected the hours of 7:00AM – 2:00PM; however, the center operates from 7:00AM to 7:00PM on Mondays, Wednesdays, and Thursdays. e. The license holder failed to maintain family and social histories for P2 and P3 that were updated annually. · P2’s family and social history was most recently updated on November 23, 2020. · P3’s family and social history was most recently updated on March 1, 2018. Repeat Violation: In Correction Orders that DHS issued on July 25, 2018 and March 23, 2021, you were cited for a similar violation. Corrective Action Ordered: Immediately, you must provide services as stated above. Compliance will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Statutes, section 245C.20, subdivision 1. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not meet background study requirements. The license holder failed to document the date SP1 had direct contact with persons served by the program in the program’s personnel file. Repeat Violation: In a Correction Order that DHS issued March 23, 2021, you were previously found in violation of this same statute. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Rules, part 9555.9650, item A. Violation: For one staff person whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. The license holder failed to maintain the following SP2’s personnel record: · SP2’s job description; · an employment application or resume; and · documentation of an annual performance evaluation in 2019, 2020, 2021, and 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP2’s personnel record; · maintain an employment application or resume in SP2’s record; and · complete a performance evaluation for SP2 and maintain documentation of the evaluation in SP2’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. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review to a mandated report as required. The license holder failed to provide SP1 and SP2 annual review in 2019, 2020, 2021, and 2022 to 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. Repeat Violation: In a Correction Order that DHS issued March 23, 2021, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, you must provide the required annual review detailed above to SP1 and SP2. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For 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 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 the required annual training to SP1 and SP2 on the topics above as required. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as written in this subpart. 11. 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 the following information 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. 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 nurse specifying conditions and terms of employment; and · maintain documentation that your registered nurse meets licensure, registration, and certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as written in this item. 13. 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 most recently documented a review of the PAPP on December 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. 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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