|
December 26, 2024 Abdifatah Abdi Nur, Authorized Agent North Side Day Services LLC 4328 Lyndale Avenue North License Number: 1085114 (Rule 223) CORRECTION ORDER Dear Abdifatah Abdi Nur: On October 23, 2024, a licensing review of North Side Day Services LLC located at 4328 Lyndale Avenue North, 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.14, subdivision 14, paragraph (c). Violation: The license holder did not meet the requirements for 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 time of day that the recipient was dropped off; and · the time of day that the recipient was picked up. Corrective Action Ordered: Immediately, you must maintain documentation of actual attendance for each adult day service recipient. 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 Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). Violation: For two of three participants whose records were reviewed (P1 and P2), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the program abuse prevention plan (PAPP) as required. a. P1 was readmitted to the center on January 10, 2024; however, the license holder failed to provide orientation to P1 on the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the PAPP within 24 hours of admission. b. The license holder failed to provide P2 orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment and the PAPP within 24 hours of admission. P2 was admitted on May 28, 2024, and the license holder maintained documentation that the orientation was provided on June 3, 2024. Corrective Action Ordered: Immediately, you must: · provide orientation to P1 on the license holder’s internal and external reporting procedures and PAPP; and · document that P1 was provided the orientation in P1’s record. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For one participant whose record was reviewed (P1), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required. P1 was readmitted to the center on January 10, 2024. The license holder failed to distribute the following policies and program information to P1 and P1’s caregivers: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the participants’ rights developed in accordance with part 9555. 9670 and additionally: o a procedure for presenting grievances, including the name, address, and telephone number of the licensing division of the department, to which a participant or participant’s caregiver may submit an oral or written complaint; o a copy or written summary of Minnesota Statutes, section 626.557, the Vulnerable Adults Act; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. Corrective Action Ordered: Immediately, you must: · distribute the policies and program information listed above to P1 and their caregivers; and · document the distribution of the policies and program information in P1’s record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For two participants whose records were reviewed (P1 and P2), the license holder did not include information in the participant’s written record as required. a. The license holder failed to include a medical report dated within three months prior to or 30 days after P1’s admission to the center in P1’s participant record. P1 was readmitted on January 10, 2024, and the license holder maintained a medical report for P1 on April 1, 2024. b. The license holder failed to include the following information in P2’s participant record: · an application form that included: o P2’s telephone number; and o the name and telephone number of P2’s physician or medical provider; · 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 P2; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P2; o a release signed by the physician indicating whether P2 may engage in a structured exercise program; and o documentation that P2 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants. Repeat Violation: In a Correction Order that DHS issued on March 31, 2022, you were previously found in violation of this same rule. 5. 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. P1 was readmitted to the center on January 10, 2024. The license holder failed to: · conduct a needs assessment for P1 within 30 days of P1’s admission that included; § o P1’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); o P1’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and o P1's physical status, determined by observation, from the intake screening interview, and from the medical report received from P1's physician; and · develop a preliminary service plan within 30 days of P1’s admission that included; o scheduled days of P1’s attendance at the center; o transportation arrangements for getting P1 to and from the center; o P1’s nutritional needs and where applicable, dietary restrictions; o the role of P1’s caregivers or caregivers in carrying out the service plan; and o services and activities in which P1 will take part in immediately upon admission. b. The license holder failed to conduct a needs assessment for P2 that addressed P2’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P2’s physician. Repeat Violation: In a Correction Order that DHS issued on March 31, 2022, you were previously found in violation of this same rule. · develop a needs assessment and preliminary service plan for P1 with the information detailed above; and · update P2’s needs assessment to include P2’s physical status based on information received from P2’s medical report. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P1 and P2), 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 within 90 days of admission to the center that included: · an update of the preliminary service plan and additional services required by P1; · short and long term objectives for P1 stated in concrete, measurable and time specific outcomes; · the staff members responsible for implementing the individual plan of care; · the anticipated duration of the individual plan of care as written; and · provisions for quarterly reviews and quarterly revisions of the individual plan of care. b. The license holder failed to develop a written plan of care for P2 within 90 days of admission to the center that included an update of the preliminary service plan. P2 was admitted to the center on May 28, 2024. The license holder developed a written plan of care for P2 on September 21, 2024. Repeat Violation: In a Correction Order that DHS issued on March 31, 2022, you were previously found in violation of this same rule. · develop a written plan of care for P1 that includes the information detailed above; and · update P2’s written plan of care to include an update of the preliminary service plan. 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 9555.9650, items B. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the registered nurse’s personnel record. Corrective Action Required: Within 30 days of receiving this order, you must maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment for your registered nurse in their personnel record. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of two staff persons whose record was reviewed (SP1), the license holder did not provide orientation to a mandated reporter as required. The license holder failed to provide SP1 orientation 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 within 72 hours of first providing direct contact. Corrective Action Required: Immediately, you must provide the required orientation detailed above to SP1. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Rules, 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 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 SP1 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 Required: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP1. 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, 6, 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 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. b. The license holder failed to maintain a monthly plan for diversified daily program activities designed to meet the needs and interests of the participants that includes: · socialization activities, such as group projects and recreational activities; · cultivation of personal interests, such as arts, crafts, and music; and · activities designed to increase the participant’s knowledge and awareness of the environment and to enhance language and conceptual skills. c. The license holder failed to maintain a family and social history in P3’s record that was updated annually in 2024. § Repeat Violation: In a Correction Order that DHS issued on March 31, 2022, you were previously found in violation of this same rule. 11. Citation: Minnesota Rules, part 9555.9720, subparts 7, 8, and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure the furniture was in good repair, including a couch with torn material. b. The license holder failed to ensure the areas used by participants were free from debris, loose plaster, and peeling paint, including: · several ceiling tiles with holes; · peeling paint and chipped sheetrock throughout the facility; · an outlet with crumbling plaster around it; and · a metal fixture that was falling out of the wall with exposed plaster and screws. c. The license holder failed to ensure the rugs had nonskid backing. d. The license holder failed to ensure the emergency plans were posted in a visible place within the center. Repeat Violation: In a Correction Order that DHS issued on March 31, 2022, you were previously found in violation of this same rule. 12. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not meet the requirements for the program abuse prevention plan (PAPP). The license holder failed to ensure a copy of the PAPP was posted in a prominent location within the center. Corrective Action Ordered: Immediately, you must post a copy of your PAPP in a prominent location within the center. Compliance with this order will be reviewed on site. 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 me as soon as possible. Alexandra Devick, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
|
