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June 13, 2023 Yusuf Hassan, Authorized Agent Hiawatha Senior Center Inc 1433 E Franklin Avenue Minneapolis, Minnesota 55404 License Number: 1110405 (Rule 223) CORRECTION ORDER Dear Yusuf Hassan: On June 8, 2023, a licensing review of Hiawatha Senior Center Inc, located at 1433 East Franklin 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 (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. Corrective Action Ordered: Immediately, you must: · provide an orientation to P1, P2, and P3 on your internal and external reporting procedures and PAPP; and · document that P1, P2, and P3 were provided the orientation in P1, P2, and P3’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 one participant whose record was reviewed (P3), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P3 as part of the initial individual program plan or service plan. Corrective Action Ordered: Immediately, you must develop an IAPP for P3. Within 30 days of receiving this order, you must: · review P3’s IAPP with P3’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. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required. The license holder failed to distribute the following policies and program information to P1, P2, and P3: · 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 program information detailed above to P1, P2, and P3; and · document the distribution of the policies and program information 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, subpart 1. Violation: For five participants whose records were reviewed (P1, P2, P3, P4, and 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: · an application form that included 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 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 P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 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; and · notes on special problems, medication changes, and need for medication assistance. b. The license holder failed to include the following information in P2’s record: · a medical report, dated within the three months prior to or 30 days after P2’s admission to the center that included a report on a physical examination. P2 was admitted to the center on May 16, 2022 and the license holder maintained a medical report for P2 on November 7, 2022; · participation reports and progress notes that are recorded at least monthly; and · notes on special problems, medication changes, and need for medication assistance. c. The license holder failed to include the following information in P3’s record: · an application form that included the name and telephone number of P3's physician or medical provider; · 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 April 26, 2022; · participation reports and progress notes that are recorded at least monthly; and · notes on special problems, medication changes, and need for medication assistance. d. The license holder failed to include the following information in P4 and P6’s record: · a medical report, dated within the three months prior to or 30 days after the participant’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 the participant; 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; o documentation that the participant was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · participation reports and progress notes that are recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain all information detailed above in P1, P2, P3, P4, and P6’s participant records; · complete an audit of all participants’ records that evaluates if each participant’s written record includes all information detailed in Minnesota Rules, part 9555.9660; and · for participants whose records do not include all required information, you must develop a plan detailing how your program will maintain all required information in the participant’s record 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 part. 5. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, 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 P1’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P1’s physician; and · develop a preliminary service plan for P1 that included: o scheduled days of the participant’s attendance at the center; o the role of the participant’s caregiver or caregivers in carrying out the service plan; and o services and activities in which the participant would take part immediately upon admission. b. P2’s admission date was May 15, 2022. The license holder failed to: · conduct a needs assessment for P2 that addressed P2’s physical status determined from the medical report received from P2’s physician. The license holder conducted a needs assessment for P2 on May 15, 2022 but did not maintain a medical report from P2’s physician until November 7, 2022; and · develop a preliminary service plan for P2 that included: o scheduled days of the participant’s attendance at the center; o transportation arrangements for getting the participant to and from the center; and o the participant’s nutritional needs and, where applicable, dietary restrictions. c. The license holder failed to develop a preliminary service plan for P3 that included: · §scheduled days of the participant’s attendance at the center; and · services and activities in which the participant would take part immediately upon admission. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1 and P2 as detailed above; · develop preliminary service plans for P1, P2, and P3 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 three participants whose records were reviewed (P2, P3 and P5), 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 P2 and P3 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 P5 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: · develop written plans of care for P2, P3, and P5 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 9555.9650, item B. Violation: For two consultants whose records were reviewed, the license holder did not include all required information in the personnel record. a. The license holder failed to maintain the following in the physical therapist’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. b. The license holder failed to maintain documentation that the registered dietitian met any licensure, registration, or certification requirements required to perform the services in their personnel record. 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 physical therapist specifying conditions and terms of employment; and · maintain documentation that your physical therapist and your registered dietitian meet licensure, registration, and certification requirements required to perform the services specified in the contract. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to offer a midafternoon snack. b. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly. The only documented review of the license holder’s exercise program was dated October 1, 2022. c. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly, that included: · monitoring persons’ health status and reporting change 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, subp.2, item C. d. The license holder failed to maintain family and social histories in P2, P3, P4, and P6’s records. § Corrective Action Ordered: Immediately, you must offer a midmorning snack. Within 30 days of receiving this order, you must: · ensure your physical therapist provides consultation and review of your exercise program; · have your registered nurse provide consultation and review of your health services; and · maintain family and social histories in P2, P3, P4 and P6’s records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Rules, part 9555.9720, subparts 7 and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to rehearse the fire escape plan at least four times each year, as required. b. The license holder failed to ensure equipment and furniture was in good repair, including two chairs in the entrance to the center with torn fabric and one couch with torn fabric. Corrective Action Ordered: Immediately, you must: · ensure all equipment and furniture used by participants is in good repair; and · rehearse your fire escape plan and record the date of the rehearsal in the file of emergency plans. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts.
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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