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November 1, 2023 CERTIFIED MAIL Mohamed Ali, Authorized Agent Shifo Adult Center 373 Pederson Street Suite 101B License Number: 1091375 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Mohamed Ali: The Department of Human Services (DHS) is placing your license to provide adult day center services for Shifo Adult Center, located at 373 Pedersen Street, Saint Paul, Minnesota on conditional status for two years, beginning November 1, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On September 29, 2023, DHS licensors conducted a licensing review at your facility located at 373 Pedersen Street. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed adult day centers, citing 14 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to provide orientation to reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan; o Failure to develop and review individual abuse prevention plans; o Failure to distribute policies and program information; o Failure to maintain participants’ written records; o Failure to complete initial service planning; o Failure to develop written plans of care; o Failure to maintain personnel records; o Failure to provide required annual training to staff persons o Failure to ensure safety; and o Failure to offer services. · Chronicity: Your program received its license on August 21, 2018. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o November 1, 2023 Order of Conditional License (this order):16 Violations (10 repeat) o April 28, 2022 Correction Order 12 Violations · Severity: Many of the violations that led to the Order of Conditional License relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For two of three participants whose records were reviewed (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 P2 and P3 on the license holder’s internal and external reporting procedures and PAPP within 24 hours of admission. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c), and subdivision 2, paragraph (a).
2. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder failed to develop IAPPs for P2 and P3 as part of the participant’s initial individual program plan or service plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and section 626.557, subdivision 14, paragraph (b). 3. 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. a. The license holder failed to distribute the following policies and program information to P1 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; · 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 following policies and program information to P2 and P3 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. c. The license holder failed to distribute the participant’s rights to P2 and P3 upon admission. Rule Violated: Minnesota Rules, part 9555.9640. 4. Violation: For 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 an application form that included P1’s source of referral in P1’s record. b. The license holder failed to include the following information in P2’s record: · an application form that included: o P2’s date of admission or readmission, living arrangement, telephone number and source of referral; o the name and telephone number of the person to call in case of an emergency involving P2 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P2’s physician or medical provider; · participation reports and progress notes that were recorded at least monthly; and · a statement signed by the center director and P2 at the time of P2’s admission specifying the basis on which P2 determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions. c. The license holder failed to include the following information in P3’s record: · an application form that included: o P3’s date of admission or readmission, living arrangement and source of referral; o the name and telephone number of the person to call in case of an emergency involving P3 and the name and number of another person to call if that person cannot be reached; and o the name and telephone number of P3’s physician or medical provider; · participation reports and progress notes 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 determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions.
5. Violation: For three participants whose records were reviewed (P1, P2 and P3), the license holder did not complete initial service planning as required. a. P1 was admitted to the center on June 14, 2023. The license holder failed to: · conduct a needs assessment for P1 within 30 days of P1’s admission that addressed §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 within 30 days of P1’s admission that included: o P1’s nutritional needs and, where applicable, dietary restrictions; and o the role of P1’s caregiver or caregivers in carrying out the service plan. b. P2 was admitted to the center on July 8, 2023. The license holder failed to: · conduct a needs assessment for P2 within 30 days of P2’s admission that addressed §P2's physical status, determined by observation, from the intake screening interview, and from the medical report received from P2's physician; and · develop a preliminary service plan within 30 days of P2’s admission. Although the license holder maintained a preliminary service plan in P2’s record, it was not dated, therefore it was unable to be determined when the preliminary service plan was completed. c. P3 was admitted to the center on February 27, 2023. The license holder failed to: · conduct a needs assessment for P3 within 30 days of P3’s admission that included; § o P3’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); o P3’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and o P3's physical status, determined by observation, from the intake screening interview, and from the medical report received from P2's physician; and · develop a preliminary service plan within 30 days of P3’s admission that included; o scheduled days of P3’s attendance at the center; o transportation arrangements for getting P3 to and from the center; o P3’s nutritional needs and where applicable, dietary restrictions; o the role of P3’s caregivers or caregivers in carrying out the service plan; and o services and activities in which P3 will take part in immediately upon admission.
6. Violation: For three participants whose records were reviewed (P1, P2, 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§ the anticipated duration of the individual plan of care as written. b. The license holder failed to develop a written plan of care for P2 that included§: · an update of the preliminary service plan 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; and · the anticipated duration of the individual plan of care as written. c. The license holder failed to develop a written plan of care for P3 that included§: · an update of the preliminary service plan 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; and · the anticipated duration of the individual plan of care as written; and · provisions for quarterly review and quarterly revisions of the individual plan of care. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. PERSONNEL RECORD & CENTER COVERAGE VIOLATIONS 7. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain a copy of SP1’s job description in SP1’s personnel record. b. The license holder failed to maintain the following information in SP2’s personnel record: · a copy of SP2’s job description; and · an employment application or resume indicating that SP2 meets the requirements in part 9555.9680. Rule Violated: Minnesota Rules, part 9555.9650, item A. Repeat Violation: In a Correction Order that DHS issued on April 28, 2022, you were previously found in violation of this same rule. 8. Violation: For two consultants whose records were reviewed, the license holder did not include all required information in the personnel record as required. a. The license holder failed to maintain documentation that the physical therapist met any licensure, registration, or certification requirements required to perform services in the physical therapist’s personnel record. b. The license holder failed to maintain the following in the registered dietician’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. Rule Violated: Minnesota Rules, part 9555.9650, item B. 9. Violation: The license holder did not ensure staff coverage of the center as required. The license holder failed to have a person trained in basic first aid and certified in cardiopulmonary resuscitation and the treatment of obstructed airways present at all times in the center when participants were present. Rule Violated: Minnesota Rules, part 9555.9690, subpart 2. 10. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide in-service training annually as required. 11. Violation: For one staff person whose records was reviewed (SP1), the license holder did not provide an annual review to a mandated reporter as required. The license holder failed to provide SP1 annual review in 2023 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. 12. Violation: The license holder did not have a qualified center director as required. The license holder failed to ensure the center director (SP1) met the following requirements: · licensure by the state of Minnesota as a licensed practical nurse or completion of at least two years of postsecondary education from an accredited college, university, technical college, or correspondence school; and · completion of two years of paid or volunteer experience in planning or delivering health or social services including experience in supervision and administration; or · completion of four years of paid or volunteer experience in planning or delivering health or social services, including two years of experience in supervision or administration. Statute Violated: Minnesota Rules, part 9555.9680, subpart 1. SERVICE AND PROGRAM VIOLATIONS 13. Violation: The license holder did not offer adult day services as required. Minnesota Statute, section 245A.02, subdivision 2a defines adult day care as providing 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. The license holder failed to provide an individualized set of services as evidenced in citations 2, 5, and 6. Additionally, the license holder failed to provide a coordinated set of services including social services and nutritional services as evidenced in citation 14. Rule Violated: Minnesota Statute, section 245A.02, subdivision 2a. 14. Violation: The license holder did not offer services as required. a. The license holder failed to ensure when participants were at the center for more than four and a half hours, they were served a meal which met one-third of the recommended daily allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences, specified in Recommended Dietary Allowances. b. The license holder failed to offer a midmorning and midafternoon snack. c. The license holder failed to ensure menus for all meals and snacks were approved by a registered dietician and met all applicable state rules and laws and United States Department of Agriculture regulations. d. The license holder failed to maintain a record indicating the menu for all meals served for at least six months. e. Additionally, the license holder failed to follow their monthly plan for diversified daily program activities. The license holder provided an activity calendar that listed the following information: · 8:00 – 9:15AM Breakfast · 9:15 – 10:00AM Duha · 10:00 – 10:30AM Morning Sip, Chat and Watch News · 10:30 – 11:30AM Basic English Class · 11:30AM – 12:00PM Learning Quran · 12:00 – 12:50PM Dhuhr Prayer · 1:00 – 1:30PM Lunch · 1:30 – 2:00PM Group Exercise/Bike, Treadmill and Walking · 2:00 PM Departure During the licensing review that took place from 8:45am to 12:30pm, DHS licensors observed participants sitting on couches on their cell phones or napping and socializing amongst themselves with little interaction from staff for significant periods of time. Additionally, the license holder’s daily activity calendar reflected the hours of 8:00AM – 2:00PM, though the center operates from 7:00am to 3:00pm Monday, Tuesday, Wednesday, Thursday, and Friday. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1 and 5. 15. Violation: The license holder did not ensure safety as required. Rule Violated: Minnesota Rules, part 9555.9720, subpart 9. 16. 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 annually in 2022. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). CORRECTIVE ACTION REQUIRED You must correct the violations as described above. If you fail to demonstrate substantial compliance with adult day care requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the adult day care licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving adult day care services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. Additionally, while the license is on conditional status, you must maintain documentation of the names of individuals you’ve provided the notification to and the date the individual was provided the notification. 2. Within 30 days of receiving this order, you must: · develop a quality assurance audit tool to ensure personnel records include all required documentation and training; · develop a quality assurance audit tool to ensure participant records include all required information; and · submit the quality assurance audit tools to your DHS licensor for approval. 3. Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you must complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you must submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 4. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Prior to admitting any new participant during the duration of the conditional license, you must notify your licensor of the name and admission date of the new participant. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Alexandra.Devick@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Alexandra Devick YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all adult day care laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Adult day care centers are required to follow Minnesota Statutes, chapters 245A and 245C and Minnesota Rules, parts 9550.9600 to 9555.9730. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, HCBS Unit Supervisor, at 651-431-6591. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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