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February 12, 2024
Kifah Barre, Authorized Agent Ebyan Adult Day Care Inc 678 Randall Drive Anoka, Minnesota 55303 License Number: 1101598 (Rule 223) CORRECTION ORDER Dear Kifah Barre: On November 14, 2023, a licensing review of Ebyan Adult Day Care Inc, located at 1810 Riverside Avenue, 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 participants whose records were reviewed (P1, P2, and P4), the license holder did not maintain a written record as required. a. The license holder failed to include the following in P1’s participant record: · an application form that included P1’s living arrangement; and · a medical report dated within the three months prior to or 30 calendar days after the participant’s admission to the center. P1 was admitted on June 30, 2022, and the license holder failed to maintain a medical report for P1 until April 2023. b. The license holder failed to maintain a medical report in P2’s participant record within the three months prior to or 30 calendar days after the participant’s admission to the center. P2 was admitted on September 1, 2022, and the license holder failed to maintain a medical report for P2 until April 2023. c. The license holder failed to maintain a medical report in P4’s participant record within the three months prior to or 30 calendar days after the participant’s admission to the center. P4 was admitted on June 30, 2022, and the license holder failed to maintain a medical report for P4 until May 2023. Additionally, the license holder failed to maintain a medical report in P4’s participant record that included a report on a physical examination, updated annually in 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1’s application form to include P1’s living arrangement; and · maintain a medical report in P4’s record that includes a report on a physical examination. 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 P2), the license holder did not complete initial service planning as required. a. The license holder failed to conduct needs assessments for P1 and P2 that addressed the participant’s functional and physical status determined from the medical report received from the participant’s physician. · The license holder conducted a needs assessment for P1 on July 1, 2022 that referred to P1’s medical report; however, the license holder did not maintain a medical report from P1’s physician until April 10, 2023. · The license holder conducted a needs assessment for P2 on July 1, 2022, that referred to P2’s medical report; however, the license holder not maintain a medical report from P2’s physician until April 10, 2023. b. The license holder failed to develop preliminary service plans for P1 and P2 that included the role of the participant’s caregiver or caregivers in carrying out the service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1 and P2’s needs assessments to include an assessment of their functional status and physical status determined from the medical report received from the participant’s physician; and · update P1 and P2’s preliminary service plans to include the role of the participant’s caregiver or caregivers 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 (P3 and P4), the license holder did not review the individual plan of care as required. The license holder failed to develop individual plans of care for P3 and P4 that included provisions for quarterly review and quarterly revision. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review P3 and P4’s individual plans of care and document the review in the participant’s record; · revise P3 and P4’s individual plans of care, as needed; and · complete an audit of all participants’ written plans of care to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9650. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel files as required. a. The license holder failed to maintain documentation of an annual performance evaluation in SP1’s personnel record. b. The license holder failed to include a job description in SP2’s personnel record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a performance evaluation for SP1 and maintain documentation of the evaluation in SP1’s personnel record; and · maintain a job description in SP2’s personnel record. On an ongoing basis, you must maintain compliance as required in this part. 5. Citation: Minnesota Rule, part 9555.9690, subpart 3. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center. The license holder maintained documentation that SP1 was provided 16 hours of orientation training. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rule, part 9555.9690, subpart 4. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide annual training as required. The license holder failed to provide SP1 a minimum of eight hours of in-service training annually in 2023 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 SP1 the annual training detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9710, subparts 1 and 7. Violation: The license holder did not offer services as required. a. The license holder failed to maintain a contract with their food service provider. b. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietitian. c. The license holder failed to maintain family and social histories in P1, P2, P3, and P4’s participant records that were updated annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a contract with your food service provider; · have your menus for all meals and snacks reviewed and approved by a registered dietician; and · maintain family and social histories in P1, P2, P3, and P4’s records. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Rules, part 9555.9720, subparts 7 and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed ensure all furniture, including couches, were in good repair. b. The license holder failed to post the written plan for emergencies caused by fire and weather in a visible place. c. The license holder failed to accurately record the dates of fire drill rehearsals in the file of emergency plans. The license holder documented that a fire drill was completed on September 3, 2023 and November 5, 2023; however, these dates were Sundays. According to the center’s licensed days and hours of operation, the center does not operate on Sundays. Corrective Action Ordered: Immediately, you must: · ensure all equipment and furniture is in good repair; and · post the written plan for emergencies cause by fire and weather in a visible place in the center. On an ongoing basis, you must maintain compliance as required in these subparts. 9. Citation: Minnesota Statutes, section 245A.04, subdivision 7a. Violation: The license holder did not notify the commissioner and obtain the commissioner’s approval before making any changes that would alter the license information, including the capacity of the program, as required. The license holder failed to maintain and ensure the program’s capacity as stated on the license. The license holder’s licensed capacity was 24; however, the license holder maintained attendance records the following: · 30 participants were present at the center at noon on October 9, 2023; · 29 participants were present at the center at noon on October 10, 2023; · 30 participants were present at the center at noon on October 11, 2023; and · 26 participants were present at the center at noon on October 12, 2023. Corrective Action Ordered: Immediately, you must ensure you provide services as listed on your license, including the capacity of your program. 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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