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December 12, 2023 Mohamed Omar, Authorized Agent Hennepin Adult Day Center Inc 1170 15th Avenue Southeast Minneapolis, Minnesota 55414 License Number: 1087686 (Rule 223) CORRECTION ORDER Dear Mohamed Omar: On November 7, 2023, a licensing review of Hennepin Adult Day Center Inc, located at 1170 15th Avenue Southeast, 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.
a. The license holder failed to include the following information in P1’s record: · an application form that included P1’s source of referral; and · notes on special problems, medication changes, and need for medication assistance. b. The license holder failed to include an application form in P2’s record that included P2’s source of referral and date of birth. c. The license holder failed to include a medical report in P3’s record within the three months prior to or 30 calendar days after P3’s admission to the center. P3’s date of admission was September 1, 2022 and the license holder maintained a medical report for P3 on August 10, 2023. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, 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, P2, and P3’s participant records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 2. 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.
The license holder failed to: · conduct a needs assessment for P1 within 30 days if P1’s admission. The license holder maintained a needs assessment for P1 that was not dated; therefore, the date the needs assessment was conducted was unable to be determined; and · develop a preliminary service plan for P1 that included P1’s nutritional needs and dietary restrictions. The license holder developed a preliminary service plan that documented that P1 followed a low sodium diet; however, P1’s medical report stated P1 was on a “low sodium, low fat” diet. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct a needs assessment for P1 as detailed above; · update P1’s preliminary service plans to 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. 3. Citation: Minnesota Rules, part 9555.9700, subpart 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. The license holder failed to develop a written plan of care for P1, P2, and P3 that included short and long-term objectives stated in concrete, measurable, and time specific outcomes. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, 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 P1, P2, and P3 that include short and long-term objectives stated in concrete, measurable, and time specific outcomes; · 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. 4. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For one of three staff persons (SP3) and one consultant whose records were reviewed, the license holder did not maintain personnel records as required. a. The license holder failed to maintain a job description in SP3’s record. b. The license holder failed to maintain annual performance evaluations in SP1 and SP2’s personnel records. c. The license holder failed to maintain documentation that the registered dietician met any licensure, registration, or certification requirements required to perform services. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order you must: · maintain a job description in SP3’s personnel record; · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluation in the staff person’s personnel record; and · maintain documentation that your registered dietician meets any licensure, registration, or certification requirements required to perform services Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 5. 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 reporter as required. The license holder failed to provide SP1 and SP2 an annual review of the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder’s program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. · The license holder most recently provided SP1 review of these requirements in December 2021. · The license holder most recently provided SP2 review of these requirements in September 2021. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, you were cited for a similar violation. Corrective Action Ordered: Immediately, you must provide the required annual review detailed above to SP1 and SP2. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, part 9555.9690, subpart 3. 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 SP1 a minimum of eight hours of in-service training annually in the following areas: · areas related to care of center participants, including provision of medication assistance; and · review of parts 9555.9600 to 9555.9730. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, you were cited for a similar violation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the required in-service training detailed above to SP1 and SP2; · complete an audit of all personnel records to ensure all staff persons have received the required annual in-service training detailed above; and · for staff persons that have not received the required annual in-service training, you must develop a plan detailing how your program will provide the staff person with the required training within 60 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 subpart. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to maintain menus for all meals and snacks approved by a registered dietician and met all applicable state rules and laws and United States Department of Agriculture regulations. b. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. c. The license holder failed to maintain a family and social history for P3 that was updated annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure your registered dietician approves your menus for all meals and snacks; · have your physical therapist provide consultation and review of your exercise program; and · review P3’s family and social history and maintain documentation of the review in P3’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Rules, part 9555.9720, subparts 5 and 8. Violation: The license holder did not ensure safety requirements as required. a. The license holder failed to store chemicals that were poisonous when swallowed or inhaled or that were damaging to eyes or skin in an area not accessible to the participants. Chemicals were stores on a shelf in the women’s restroom and were accessible to participants. b. The license holder failed to ensure a rug in the center had nonskid backing. Repeat Violation: In a Correction Order that DHS issued on May 2, 2022, you were cited for a similar violation. Corrective Action Ordered: Immediately you must: · store chemicals in an area that is not accessible to participants; and · ensure rugs have nonskid backing. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as written in these subparts. 9. Citation: Minnesota Rules, part 9555.9730, subpart 3. Violation: The license holder did not equip restrooms with signal systems as required. The license holder failed to equip restrooms used by participants with a mechanism that participants could use to signal staff members by light or by sound if participants needed assistance. Corrective Action Ordered: Immediately, you must ensure restrooms used by participants are equipped with a mechanism that participants can use to signal staff members by light or by sound if participant need assistance. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not review the 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 April 2017. 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. Compliance with this order will be reviewed onsite. 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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