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September 12, 2023 Ayan Salah, Authorized Agent 2500 Minnehaha Avenue Suite 300 Minneapolis, Minnesota 55404 License Number: 1109849 (Rule 223) CORRECTION ORDER Dear Ayan Salah: On August 17, 2023, a licensing review of SM Adult Day Services LLC located at 2500 Minnehaha Avenue Suite 300, 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 Rules, part 9555.9660, subpart 1. Violation: For three of 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. a. The license holder failed to include P1’s service agreement with the center signed by P1 and the center director in P1’s record. b. The license holder failed to include the following information in P2’s record: · an application form signed by P2 that included P2’s source of referral; and · a service agreement with the center signed by P2 and the center director. c. The license holder failed to include the following information in P3’s record: · an application form signed by P3 that included P3’s telephone number; · a medical report that included: o a report on P3’s physical examination; and o a medical history of P3; · a service agreement with the center signed by P3 and the center director; and · notes on special problems, medication changes, and need for medication assistance. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain all information detailed above in P1, P2, and P3’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. On an ongoing basis, you must maintain compliance as required in this subpart. 2. 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 P3 that addressed P3’s physical status determined from the medical report received from P3’s physician. The license holder conducted a needs assessment for P3 on May 16, 2023 but did not maintain a medical report from P3’s physician until May 22, 2023. b. The license holder failed to develop a preliminary service plan for P1 that included the role of P1’s caregiver in carrying out the service plan. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P3’s needs assessment to address P3’s physical status determined from the medical report received from P3’s physician; and · update P1’s preliminary service plan to include the role of P1’s caregiver in carrying out the service plan. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not develop a written plan of care as required. The license holder failed to develop written plans of care for P1 and P2 that included short and long term objectives for P1 and P2 stated in concrete, measurable, and time specific outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must develop written plans of care for P1 and P2 that include short and long term objectives for P1 and P2 stated in concrete, measurable, and time specific outcomes. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9720, subpart 9. Violation: The license holder did not ensure safety as required.
The license holder failed to rehearse the fire escape plan at least four times each year. Corrective Action Ordered: Immediately, you must rehearse your fire escape plan and record the date of the rehearsal in the file of emergency plans. 5. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not review 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. The license holder most recently documented a review of the PAPP in June 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 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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