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November 4, 2024 CERTIFIED MAIL Abdurahim Buse, Authorized Agent Sunshine Adult Day Care Center 918 Park Street St. Paul, Minnesota 55117 License Number: 1082009 (Rule 223) ORDER OF CONDITIONAL LICENSE Dear Abdurahim Buse: The Department of Human Services (DHS) is placing your license to provide adult day care services at Sunshine Adult Day Care Center, located at 775 Milton Street North, St. Paul, Minnesota on conditional status for two years, beginning November 4, 2024. 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 18, 2024, DHS licensors conducted a licensing review at your facility located at 775 Milton Street North, St. Paul, Minnesota. As a result of this licensing visit, DHS determined that your program failed to comply with the laws and rules that apply to licensed adult day centers, citing 11 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 develop and review individual abuse prevention plans; o Failure to maintain attendance record documentation; 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 staff and consultant personnel records; o Failure to provide staff annual in-service training; o Failure to ensure safety; o Failure to offer services; o Failure to establish and enforce their program abuse prevention plan (PAPP). · Chronicity: Your program received its license on September 26, 2017. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o October 17, 2022 Correction Order: 12 Violations o January 31, 2023 Correction Order: 12 Violations (8 repeat) o November 4, 2024 Conditional License (this order): 12 Violations (7 repeat) · 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 (P1 and P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P1 that included a statement of measures that would be taken to minimize the risk of abuse to P1 and other vulnerable adults when the IAPP indicated susceptibility to abuse. b. The license holder failed to review P1 and P2’s IAPPs with their interdisciplinary team, at least annually in 2024, using the individual assessment and any reports of abuse relating to the person. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1’s IAPP to include a statement of measures that will be taken to minimize the risk of abuse to P1 and other vulnerable adults when the individual assessment indicates the need for measures; and · review P1 and P2’s IAPPs with the person’s interdisciplinary team and document the review. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. 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 the following information in P1’s record: · an application form that included the telephone number of a secondary person to call in case of an emergency involving P1; · a medical report dated within the three months prior to or 30 days after P3’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 P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 is free from communicable disease or infestations, as specified in parts 4605.700 to 4605.7090, that would endanger the health of other participants; · participation reports and progress notes that were recorded at least monthly; and · notes on special problems, medication changes, and need for medication assistance. b. The license holder failed to maintain the following information in P2’s record: · an application form that included the telephone number of a secondary person to call in case of an emergency involving P2; and · a medical report that included a report on a physical examination, updated annually. The most recent report on a physical examination that the license holder maintained for P2 was dated June 20, 2023. c. The license holder failed to maintain the following information in P3’s record: · an application form that included the telephone number of a secondary person to call in case of an emergency involving P3; and · a medical report dated within the three months prior to or 30 days after P3’s admission to the center. P3 was admitted to the center on January 27, 2023 and the license holder maintained a medical report for P3 on September 5, 2024. Rule Violated: Minnesota Rules, part 9555.9660, subparts 1 and 3. Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1, P2 and P3’s participant record. On an ongoing basis, you must maintain compliance as required in this part. 3. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder failed to: · conduct a needs assessment for P1 that addressed P1’s physical status determined from the medical report received from P1’s physician; and · develop a preliminary service plan for P1 that included P1’s nutritional needs and, where applicable, dietary restrictions. b. The license holder failed to conduct needs assessments for P2 and P3 that addressed the participant’s physical status using information from the medical report received from the participant’s physician. · The license holder conducted P2’s needs assessment on April 13, 2023; however, the license holder did not receive the medical report from P2’s physician until June 20, 2023. · The license holder conducted P3’s needs assessment on January 30, 2023; however, the license holder did not receive the medical report from P3’s physician until September 5, 2024. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1, P2, and P3’s needs assessments to address the participant’s physical status determined from the medical report received from the participant’s physician; · update P1’s preliminary service plan to include P1’s nutritional needs and, where applicable, dietary restrictions; · 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 and preliminary service plan within 60 calendar days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For one participant whose record was reviewed (P2), 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 that included short and long term objectives for P2 stated in concrete, measurable, and time specific outcomes. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same rule. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a written plan of care for P2 that includes short and long term outcomes for P2 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. On an ongoing basis, you must maintain compliance as required in this subpart. PERSONNEL RECORD AND CENTER COVERAGE VIOLATIONS 5. Violation: For three of three staff persons (SP1, SP2, and SP3) and one consultant whose records were reviewed, 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 in 2023 and 2024. b. The license holder failed to maintain the following in SP2 and SP3’s personnel records: · the employee’s job description; and · an employment application or resume indicating that the employee met the requirements in part 9555.9680, subpart 2. c. The license holder failed to maintain a personnel file for the registered nurse that included a copy of a signed contract or letter of appointment specifying conditions and terms of employment. Rule Violated: Minnesota Rules, part 9555.9650, items A and B. Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same rule. 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; · maintain a job description in SP2 and SP3’s personnel records; · maintain an employment application or resume in SP2 and SP3’s records; and · maintain a personnel file for the registered nurse that includes a copy of a signed contract or letter of appointment specifying conditions and terms of employment. On an ongoing basis, you must maintain compliance as required in these items. 6. Violation: For one of three staff persons whose record was reviewed (SP3), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP3 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. Corrective Action Ordered: Immediately, you must provide the required orientation detailed above to SP3. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Violation: The license holder did not ensure staff coverage of the center as required. The license holder failed to have a person certified in cardiopulmonary resuscitation (CPR) and the treatment of obstructed airways present at all times: · in the center when participants were present; · in a vehicle being used by the center to transport participants; and · with participants on field trips or other activities conducted by the center away from the center site. At the time of the licensing review, there was one staff present at the center that was not certified in CPR and the treatment of obstructed airways. Additionally, there were two staff on a field trip with participants away from the center that were not certified in CPR and the treatment of obstructed airways. Rule Violated: Minnesota Rules, part 9555.9690, subpart 2. Corrective Action Ordered: Immediately, you must ensure a staff person certified in cardiopulmonary resuscitation and the treatment of obstructed airways is present at all times. On an ongoing basis, you must maintain compliance as required in this subpart. 8. 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 in 2023 and 2024.
Rule Violated: Minnesota Rules, part 9555.9690, subpart 4. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1 and SP2. On an ongoing basis, you must maintain compliance as required in this subpart. SERVICE AND PROGRAM VIOLATIONS 9. Violation: The license holder did not meet the requirements attendance record documentation. The license holder failed to maintain documentation of actual attendance for each adult day service recipient for which the license holder was reimbursed by a governmental program that included: · the first, middle, and last name of the recipient; · the time of day that the recipient was dropped off; and · the time of day that the recipient was picked up. Statute Violated: Minnesota Statutes, section 245A.14, subdivision 14, paragraph (c). Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same statute. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Violation: The license holder did not offer services as required. a. The license holder had food prepared off-site but failed to maintain a current and accurate contract with the food service provider. Additionally, the license holder failed to maintain a record indicating the menu for all meals served for at least six months. 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 refrigerator had a temperature of 47.8 degrees Fahrenheit. c. 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. d. 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. e. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly. The license holder maintained reviews from April 2023 and August 2024. Rule Violated: Minnesota Rules, part 9555.9710, subparts 1, 3, and 4. Repeat Violation: In a Correction Order that DHS issued on January 31, 2023, you were previously found in violation of this same rule. Corrective Action Ordered: Immediately, you must provide services as stated above. On an ongoing basis, you must maintain compliance as required in these subparts. SAFETY VIOLATIONS 11. Violation: The license holder did not meet safety requirements. a. The license holder failed to ensure a first aid kit and manual was taken on field trips. At the time of the licensing review, staff and participants were on a field trip; however, the license holder stated a first aid kit and manual was not taken. b. 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 stored accessible to participants in the kitchen area. c. The license holder failed to ensure areas used by participants were free from peeling paint. d. The license holder failed to have written plans for emergencies caused by fire that included: · instructions on closing off the fire area; and · Instructions on location and use of fire extinguishers. Rule Violated: Minnesota Rules, 9555.9720, subparts 1, 5, 8, and 9. Corrective Action Ordered: Immediately, you must ensure: · a first aid kit and manual is taken on field trips; · chemicals that are poisonous when swallowed or inhaled or that are damaging to eyes or skin are stored in an area not accessible to the participants; and · plans for emergencies caused by fire include the information detailed above. Within 30 days of receiving this order, you must ensure areas used by participants are free from peeling paint. On an ongoing basis, you must maintain compliance as required in these subparts. POLICY AND PROCEDURE VIOLATIONS 12. 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 at least annually, using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 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 15 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; and · 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. The date that all participant and personnel records will be brought into compliance must be no later than within 90 days of receiving this order. 4. During the first three months of your conditional license and until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards, no new admissions will be allowed. During the duration of the conditional license, you must notify your licensor and receive approval prior to admitting new participants to your program. The notification to your licensor must include the name of the participant, the participant’s anticipated date of admission, documentation of compliance with term 1 of your conditional license, and your plan to meet compliance with individual service planning requirements. 5. You may not increase the hours or days of operation of you program or increase the capacity of your program for the duration of the conditional license. Submissions required as part of a corrective action ordered must be sent to your Licensor: 1. by secure email at: Katie.Johnson@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Katie Johnson 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 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 Katie Johnson, HCBS Licensor, at 651-431-4113. Sincerely, Brittany Raddatz, HCBS Unit Supervisor Licensing Division Office of Inspector General
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