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December 1, 2023 CERTIFIED MAIL Lensa Mohamed, Authorized Agent Open Arms Corp 1702 Nicollet Avenue Apartment 313 Minneapolis, Minnesota 55403-2869 License Number 1076264 (Rule 223) ORDER OF LICENSE REVOCATION Dear Lensa Mohamed: The Department of Human Services (DHS) is revoking your license to provide adult day services at 624 East Lake Street, Minneapolis, Minnesota. This revocation is based on conditional license violations and failure to comply with licensing rules and laws. Details of our findings are provided below. Our next steps and your options are also detailed. The revocation goes into effect on December 15, 2023 at 5pm to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. REASON FOR LICENSE REVOCATION 1. Conditional license violations DHS issued an Order of Conditional License, dated February 3, 2023. The conditional license was effective for a period of two years to February 3, 2025. The Order of Conditional License included terms that you were required to meet for the duration of the conditional license. DHS has determined that you failed to comply with Term #3 of the Order of Conditional License. Term #3: Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you were ordered to complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you were ordered to submit the date to your DHS licensor that all participant and personnel records would be brought into compliance based on the results of your audit.
On August 16th, 2023, you emailed your licensor reporting all participant and personnel records would be brought into compliance based on the results of your audit by September 18th. You failed to bring all participants and personnel records into compliance by September 18th, 2023, as evidenced in licensing violations 1 through 8 detailed in this order. Legal Authority: Minnesota Statutes, sections 245A.06, subdivision 3; and 245A.07, subdivision 3(a). 2. Failure to comply with licensing laws and rules DHS determined that your program failed to fully comply with the laws and rules that apply to licensed adult day services. DHS has also considered the nature, chronicity, or severity of the violations that led to the revocation of your license. · Nature: o Failure to establish written policies and procedures o Failure to maintain participant 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 offer services o Failure to ensure safety o Failure to ensure physical plant and space requirements · Chronicity: Your program received its license on June 10, 2015. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o December 1, 2023 Revocation (this order): 8 violations (7 repeat) o February 3, 2023 Conditional License: 13 violations (9 repeat) o December 9, 2022 Temporary Immediate Suspension: Imminent risk of harm to persons served o September 13, 2022 Correction Order: 10 violations (7 repeat) o February 4, 2019 Correction Order: 15 violations (8 repeat) o November 29, 2016 Correction Order: 20 violations · Severity: Many of the violations that led to the revocation of your license relate to the health and safety of persons served. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1). 3. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of persons served by your program, and information about the qualifications of staff persons that are working in your program. In the time since your program has been licensed, you have continued to demonstrate significant and ongoing noncompliance with licensing rules and statutes. Specifically, you failed to comply with licensing laws and standards even after given notice the Conditional License Order showing your inability to follow the laws and rules in place intended to ensure the health and safety of vulnerable adults. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. 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 revoked. LICENSING VIOLATIONS DETERMINED ON SEPTEMBER 25, 2023 DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For six of six participants whose records were reviewed (P1, P2, P3, P4, P5 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: o P1’s source of referral; and o the name and telephone number of the person to call in case of an emergency involving P1 and the name and number of another person to call if that person cannot be reached; · a medical report, dated within the three months prior to or 30 days after the participants’ admission to the center signed by a physician, or physician assistant or registered nurse and cosigned by a physician, that included: 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; and 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 · 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: · an application form that included P2’s living arrangement and source of referral; and · attendance and participation reports and progress notes that were recorded at least monthly. c. The license holder failed to include a medical report, dated within the three months prior to or 30 days after the participants’ admission to the center. P3 was admitted to the center on May 1, 2023 and the license holder obtained a medical report for P3 on September 2, 2023. d. The license holder failed to include a discharge summary in P4, P5, and P6’s records. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. · Correction Order dated November 29, 2016; · Correction Order dated February 4, 2019; · Correction Order dated September 13, 2022; and · Order of Conditional License dated February 3, 2023. 2. Violation: For three participants whose records were reviewed (P1, P2 and P3), the license holder did not complete initial service planning as required. The license holder failed to conduct needs assessments for P1, P2 and P3 that included the participant’s physical status determined from the medical report received from the participant’s physicians. The license holder conducted P1, P2 and P3’s needs assessments prior to obtaining the participants medical reports. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2.
· Correction Order dated November 29, 2016; · Correction Order dated February 4, 2019; · Correction Order dated September 13, 2022; and · Order of Conditional License dated February 3, 2023. 3. 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: · short- and long-term objectives for P1 stated in concrete, measurable, and time specific outcomes; and · 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 person. c. The license holder failed to develop a written plan of care for P3 that included the anticipated duration of the individual plan of as written.
Repeat Violation: You were previously found in violation of this same subpart in the following orders issued by DHS: · Correction Order dated November 29, 2016; · Correction Order dated February 4, 2019; · Correction Order dated September 13, 2022; and · Order of Conditional License dated February 3, 2023. PERSONNEL RECORD VIOLATIONS 4. Violation: For one of three staff persons (SP3) and two consultants whose records were reviewed, the license holder did not maintain a personnel record as required. a. The license holder failed to maintain the following in SP3’s personnel record: · SP3’s job description; and · an employment application or resume indicating that SP3 met the requirements in part 9555.9680, subpart 2. b. The license holder failed to maintain the following 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. c. The license holder failed to maintain copy of a signed contract or letter of appointment specifying conditions and terms of employment in the registered dietician’s personnel record. Rule Violated: Minnesota Rules, part 9555.9650, items A and B. · Correction Order dated February 4, 2019; and · Order of Conditional License dated February 3, 2023. SERVICE AND PROGRAM VIOLATIONS 5. Violation: The license holder did not offer services as required. a. The license holder failed to follow the procedures for preparing, handling, and serving food, and washing food, utensils, and equipment must comply with chapter 4626, requirements for Food and Beverage Establishments, and with applicable local ordinances. At the time of licensing review, DHS licensors observed the following: · food items in the refrigerator that were expired and moldy; and · toast, juice, coffee, and jelly being served to participants by staff without a food license. The license holder’s food license expired on April 1, 2020. b. The license holder failed to ensure the refrigerator had a temperature of 40 degrees Fahrenheit or less. At the time of the licensing review, the thermostat in the refrigerator indicated a temperature of 61 degrees Fahrenheit. c. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietitian and met all applicable state rules and law and US Department of Agriculture regulations. d. The license holder failed to maintain a current and accurate contract with their food service provider that prepared food off-site. e. The license holder failed to maintain a record indicating the menu for all meals served for at least six months. f. 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. g. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1, 3 and 4. · Correction Order dated November 29, 2016; · Correction Order dated February 4, 2019; · Correction Order dated September 13, 2022; and · Order of Conditional License dated February 3, 2023. SAFETY VIOLATIONS 6. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure rugs had nonskid backing. b. The license holder failed to ensure the emergency plans were posted in a visible place in the center. c. The license holder failed to rehearse the fire escape plan for the first three quarters of 2023. Rule Violated: Minnesota Rules, part 9555.9720, subparts 8 and 9. 7. Violation: The license holder did not ensure physical plant and space requirements.
The license holder failed to ensure a minimum temperature of 70 degrees Fahrenheit was maintained in indoor areas used by people receiving services. At the time of review, the thermostat read 68 degrees Fahrenheit. Rule Violated: Minnesota Rules, part 9555.9730, subpart 7. POLICY AND PROCEDURE VIOLATIONS 8. Violation: The license holder failed to establish written policies and procedures related to suspected or alleged maltreatment of vulnerable adults as required. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (a), part (2). · Correction Order dated September 13, 2022; and · Order of Conditional License dated February 3, 2023. YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. 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. Please send it 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 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 Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. · The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). · If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). · Minnesota Statutes, section 626.557, subdivision 9c, paragraph (d), when substantiated maltreatment is determined to have been committed by an individual who is also the facility license holder, both the individual and the facility must be determined responsible for the maltreatment. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, Supervisor, at 651-431-6591. Sincerely,
Jill Slaikeu, Unit Manager Licensing Division Office of Inspector General
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