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December 26, 2023
Adamu Betel, Authorized Agent Long Live Adult Day Center LLC 17323 County Road 6 Plymouth, Minnesota 55447 License Number: 1108860 (Rule 223) CORRECTION ORDER Dear Adamu Betel: On November 9, 2023, a licensing review of Long Live Adult Day Center LLC, located at 4000 28th Avenue South, 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 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For two of three 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 review P2 and P3’s IAPPs quarterly as part of the review of the program plan or service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must review P2 and P3’s IAPPs with the person’s interdisciplinary team and document the review. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose record was 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 the following information in P1’s record: · a medical report dated within the 3 months prior to or 30 calendar days after P1’s admission to the center. P1 was admitted on May 9, 2022 and the license holder maintained a medical report for P1 on July 10, 2023; and · participation reports and progress notes that were recorded at least monthly. b. The license holder failed to include the following information in P2’s record: · an application form that included P2’s source of referral; · a medical report, dated within the three months prior to or 30 days after P2’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; 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; 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; · 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 P3’s date of admission and source of referral; · a medical report, dated within the three months prior to or 30 days after P3’s admission to the center that included a report on a physical examination. P3 was admitted to the center on October 18, 2022 and the license holder maintained a medical report for P3 on June 29, 2023; · participation reports and progress noted that are recorded at least monthly; 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 the information detailed above in 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. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records was reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder failed to develop a needs assessment for P1 that addressed the participant’s physical status determined from the medical report received form the participant’s physician. The license holder developed P1’s needs assessment on June 7, 2022; however, the license holder did not maintain a medical report for P1 until July 10, 2023. b. The license holder failed to conduct a needs assessment for P2 that included P2’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P2’s physician. c. 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 November 14, 2022; however, the license holder did not maintain a medical report for P3’s until June 29, 2023; and · develop a preliminary service plan for P3 that included P3’s nutritional needs and, where applicable, dietary restrictions. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1, P2, and P3’s needs assessments to include information from the medical report received from P1, P2, and P3’s physician; and · update P3’s preliminary service plan to include P3’s nutritional needs and, where applicable, dietary restrictions. 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 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (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 P2 and P3 that included: · short and long term objectives for the person stated in concrete, measurable, and time specific outcomes; · 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. §Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P2 and P3 that include the information detailed 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. 5. Citation: Minnesota Rules, part 9555.9650, item A. 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 job description in SP1 and SP2’s personnel records. b. The license holder failed to maintain documentation of annual performance evaluations in SP1 and SP2’s personnel records. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP1 and SP2’s personnel records; and · complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 6. 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 orientation and annual review to a mandated reporter as required. a. The license holder failed to provide SP1 and SP2 orientation to 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 (PAPP), and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact. b. The license holder failed to provide SP1 and SP2 annual review in 2022 and 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. Corrective Action Ordered: Immediately, you must provide the required orientation and annual review detailed above to SP1 and SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. 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 orientation to the center as required. The license holder failed to provide SP1 and SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least four hours of supervised orientation before the employee worked directly with persons at the center; · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1 and SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Rules, part 9555.9690, subpart 4. 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 SP2 a minimum of eight hours of in-service training annually in areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1 and SP2. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 9. Citation: Minnesota Rules, part 9555.9690, subpart 2. Violation: The license holder did not provide adequate staff coverage of the center as required. The license holder failed to have a staff person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times. Corrective Action Ordered: Immediately, you must maintain staff coverage of the center which includes having a staff person trained in basic first aid and certified in cardiopulmonary resuscitation, and the treatment of obstructed airways present at all times. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 10. Citation: Minnesota Rules, part 9555.9710, subparts 3 and 7. Violation: The license holder did not offer services as required. a. The license holder failed to ensure a registered nurse provided consultation and review of the health services at least monthly, that included: · monitoring a person’s health status and reporting changes 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, subpart 2, item C. b. The license holder failed to maintain a family and social history in P1’s record that was reviewed annually. Corrective Action Ordered: Immediately, you must provide health services as detailed above. Within 30 days of receiving this order, you must review P1’s family and social history and maintain documentation of this review in P1’s record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 11. Citation: Minnesota Rules, part 9555.9720, subparts 1 and 9. Violation: The license holder did not ensure safety as required.
a. The license holder failed to maintain a first aid kit that contained a thermometer. b. The license holder failed to have written plans for emergencies caused by fire, that included instructions on location of fire extinguishers. c. The license holder failed to rehearse the fire escape plan at least four times in 2022 and 2023. Corrective Action Ordered: Immediately, you must: · maintain a first aid kit that includes a thermometer; · develop written plans for emergencies caused by fire that include instructions on location of fire extinguishers; 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 on site. On an ongoing basis, you must maintain compliance as required in these subparts. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not to post a copy of the program abuse prevention plan in a prominent location in the program as required. Corrective Action Ordered: Immediately, you must post your program abuse prevention plan in a prominent location in the program. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 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, Katie Johnson, at 651-431-4113. Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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