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January 21, 2025
Abdullahi Husein, Authorized Agent Salaama Adult Day Center LLC 2834 Stevens Avenue Minneapolis, Minnesota 55408 License Number: 1100878 (Rule 223) CORRECTION ORDER Dear Abdullahi Husein: On December 11, 2024, a licensing review of Salaama Adult Day Center LLC, located at 2834 Stevens 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 Statutes, section 245A.65, subdivision 1, paragraph (a), part (2). Violation: The license holder did not establish written policies and procedures related to suspected or alleged maltreatment as required. The license holder failed to identify the secondary person or position to whom internal reports may be made and the secondary person or position responsible for forwarding the internal reports to the common entry point. Corrective Action Ordered: Immediately, you must update your policies and procedures related to suspected or alleged maltreatment of vulnerable adults to include the secondary person or position to whom internal reports may be made and a secondary person or position responsible for forwarding the internal reports to the common entry point. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3.
a. The license holder failed to review P2-P4’s IAPPs quarterly as part of the review of the program plan or service plan. b. The license holder failed to review P1-P5’s IAPPs with their interdisciplinary team, at least annually, using the individual assessment and any reports of abuse relating to the participant.
3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1-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 three months prior to or 30 calendar days after P1’s admission to the center, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that includes a report on a physical examination, updated annually. b. The license holder failed to include the following information in P2’s record: · an application form for P2 that included the name and telephone number of the person to call in case of an emergency involving the participant and the name and number of another person to call if that person cannot be reached; · a medical report that included a report on a physical examination, updated annually; and · progress notes that are recorded at least monthly. c. The license holder failed to include the following in P3’s record: · a medical report that included a report on a physical examination, updated annually; and · progress notes that are recorded at least monthly. Corrective Action Ordered: Within 30 days of receiving this order, you must include the information detailed above in P1, P2, and P3’s records. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For five participants whose records were reviewed (P1-P5), the license holder did not develop a written plan of care as required. a. The license holder failed to develop written plans of care for P1 and P5 that included the anticipated duration of the individual plan of care as written. b. The license holder failed to develop written plans of care for P2-P4 that included: · 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 P1-P5 that include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For one of two staff persons (SP1) and two consultants 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. b. 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. c. The license holder failed to maintain documentation that the registered dietician met any licensure, registration, or certification required to perform the services specified in the contract. 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 copy of a signed contract or letter of appointment with your registered nurse specifying conditions and terms of employment; and · maintain documentation that your registered dietician meets licensure, registration, or certification required to perform the services specified in the contract. On an ongoing basis, you must maintain compliance as required in these items. 6. Citation: Minnesota Rules, part 9555.9710, subparts 1, 3, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to ensure the menus for all meals and snacks were approved by a registered dietician and met all applicable state rules and laws and United Stated Department of Agriculture regulations. b. 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. c. The license holder failed to ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly, in 2023 and 2024. d. The license holder failed to maintain family and social histories in P1-P4’s records that were updated annually. Corrective Action Ordered: Within 30 days of receiving this order, you must: · ensure menus for all meals and snacks are approved by a registered dietician; · ensure a registered nurse provides consultation and review of the health services at least monthly; · ensure a registered physical therapist provided consultation and review of the exercise program, at least quarterly; and · review and update P2-P4’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in these subparts. 7. Citation: Minnesota Rules, part 9555.9720, subparts 7, 8, and 9. Violation: The license holder did not meet safety requirements. a. The license holder failed to ensure equipment was in good repair, including a nonskid rug that was curling up at the edges. b. The license holder failed to ensure areas used by participants are free from peeling paint. c. The license holder failed to ensure plans for emergencies caused by fire, blizzards, and tornadoes were posted in a visible place in the center. Corrective Action Ordered: Immediately, you must: · ensure equipment is in good repair; and · ensure plans for emergencies caused by fire, blizzards, and tornadoes are posted in a visible place in the center. 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. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder did not establish a program abuse prevention plan (PAPP) as required. On December 11, 2024, DHS licensors observed unhoused individuals directly outside of the adult day center. This observation was discussed with the center director on December 11, 2024. The center director informed DHS licensors that a few months prior some of the unhoused individuals broke into the center and caused some damage and destruction; however, the license holder failed to include this assessment of the environment for the center, including the location of the program in a particular neighborhood, within their PAPP. Corrective Action Ordered: Immediately, you must review your PAPP using the assessment factors in the plan and ensure an accurate assessment of the environment for your facility, including the location of your program in a particular neighborhood, is included in your PAPP. Within 30 days of receiving this order, you must review your PAPP. 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 me as soon as possible. Katie Johnson, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4113
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