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March 17, 2025 CERTIFIED MAIL Mohamed Ali, Authorized Agent Shifo Adult Center Inc 373 Pedersen Street Suite 101B Saint Paul, Minnesota 55119-4408 License Number 1091375 (Rule 223) ORDER OF LICENSE REVOCATION Dear Mohamed Ali: The Department of Human Services (DHS) is revoking your license to provide adult day services at 373 Pedersen Street, Saint Paul, Minnesota. This revocation is based on conditional license violations and failure to comply with licensing rules and laws. Details of our findings are provided below. Our next steps and your options are also detailed. The revocation goes into effect on April 1, 2025 at 3:00 p.m. to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below. REASON FOR LICENSE REVOCATION 1. Conditional license violations DHS issued an Order of Conditional License, dated May 6, 2024. The conditional license was effective for a period of two years. The Order of Conditional License included terms that you were required to meet for the duration of the conditional license. DHS has determined that you failed to comply with Term #3 of the Order of Conditional License because failed to bring personnel records into compliance by the date you submitted to DHS. Term #3: Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you were ordered to complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you were ordered to submit the date to your DHS licensor that all participant and personnel records would be brought into compliance based on the results of your audit.
You violated Term 3 of the Conditional License because you did not bring all participant and personnel records into compliance by November 19, 2024. Legal Authority: Minnesota Statutes, sections 245A.06, subdivision 3; and 245A.07, subdivision 3(a). 2. Failure to comply with licensing laws and rules DHS determined that your program failed to fully comply with the laws and rules that apply to licensed adult day services. DHS has also considered the nature, chronicity, or severity of the violations that led to the revocation of your license. · Nature: o Failure to provide orientation to the license holder’s internal and external reporting procedures o Failure to meet the requirements for individual abuse prevention plans o Failure to maintain participant records o Failure to complete initial service planning o Failure to develop written plans of care o Failure to maintain personnel records o Failure to provide staff orientation and annual review to a mandated reporter o Failure to provide orientation to the center o Failure to provide in-service training annually o Failure to offer services o Failure to ensure safety · Chronicity: Your program received its license on August 21, 2018. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o April 28, 2022 Correction Order: 12 violations o November 1, 2023 Conditional License: 16 violations (10 repeat) o August 28, 2024 Correction Order: 2 violations o March 17, 2025 Revocation (this order): 11 violations (2 repeat) · Severity: The violations that led to the revocation of your license relate to the health and safety of persons served. DHS found that you failed to maintain compliance during four DHS compliance monitoring visits and after three licensing actions. Your continued inability to maintain compliance while providing services presents concerns related to your ability to ensure the health and safety of persons currently served now and in the future. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1). 3. Commissioner’s evaluation of program In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the program’s operation; well-being of persons served by your program; available evaluations of the program by persons receiving services; information about the qualifications of the personnel employed by you; and your ability to demonstrate competent knowledge of the applicable requirements of statutes and rules. Since your program has been licensed, you have continued to demonstrate significant and ongoing noncompliance with licensing rules and statutes. You failed to comply with licensing laws even while operating on a conditional license. On November 22, 2024, DHS licensors requested to review the corrective action you completed to bring participant and personnel records into compliance. You produced an audit that indicated the records were in compliance; however, as evidenced by citations 1-9, records remained noncompliant. Your inability to accurately complete an audit, after receiving guidance from DHS, demonstrates a lack of competent knowledge of applicable statutes and rules. Regarding the qualifications of the persons employed by you, your records show they were not properly trained. Based on the violations and Commissioner’s evaluation of the program, DHS is concerned about your ability to ensure the safety and well-being of vulnerable adults who are served by your program. Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6. 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 revoked. LICENSING VIOLATIONS DETERMINED ON NOVEMBER 22, 2024 DHS determined that your program failed to follow licensing rules and statutes, as described below. PARTICIPANT RECORD VIOLATIONS 1. Violation: For one participant whose record was reviewed (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. The license holder failed to provide orientation to P2 on the licensor holder’s internal and external reporting procedures and PAPP within 24 hours of admission. P2 was admitted to the center on March 19, 2024. The license holder provided P2 the required orientation on March 25, 2024. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c) and subdivision 2, paragraph (a). 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop IAPPs for P1 and P2 as part of the participant’s initial individual program plan or service plan. b. The license holder failed to review P3’s IAPP with P3’s interdisciplinary team at least annually. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). 3. 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 the following information in P1’s record: · an application form signed by P1 or P1’s caregiver that included: o P1’s date of birth; o P1’s date of admission or readmission; and o the name and telephone number of P1's physician or medical provider; · a medical report, dated within the three months prior to or 30 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; and · participation reports and progress notes that are recorded at least monthly. b. The license holder failed to include 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 in the record. Rule Violated: Minnesota Rules, part 9555.9660, subpart 1. 4. 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 maintained a need assessment and preliminary service plan in P1’s record that were not dated; therefore, it was unable to be determined if the license holder conducted P1’s needs assessment and developed P1’s preliminary service plan within 30 days of P1’s admission. b. The license holder maintained a needs assessment in P2’s record that was not dated; therefore, it was unable to be determined if the license holder conducted P2’s needs assessment within 30 days of P2’s admission. Rule Violated: Minnesota Rules, part 9555.9700, subpart 2. 5. Violation: For three participants whose records were reviewed (P1, P2, and P3), 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 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; and · the staff members responsible for implementing the individual plan of care. b. The license holder failed to develop written plans of care for P2 and P3 that included§: · short and long term objectives for the participants stated in concrete, measurable and time specific outcomes; and · the staff members responsible for implementing the individual plan of care. Rule Violated: Minnesota Rules, part 9555.9700, subpart 3. PERSONNEL RECORD VIOLATIONS 6. Violation: For three of three staff persons (SP1, SP2, and SP3) and three consultants whose records were reviewed, the license holder did not maintain a personnel record as required. a. The license holder failed to maintain documentation of an annual performance evaluation for SP1 and SP3 in SP1 and SP3’s personnel records. b. The license holder failed to maintain a copy of a job description in SP2’s personnel record. c. 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, registered dietician, and physical therapist’s personnel records. Rule Violated: Minnesota Rules, part 9555.9650, items A and B. 7. Violation: For three staff persons whose records were reviewed (SP1, SP2 and SP3), the license holder did not provide orientation and annual review to a mandated reporter as required. a. The license holder failed to provide SP2 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. b. The license holder failed to provide SP1 and SP3 annual review 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. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3. 8. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · training related to the kinds of functional impairments of persons currently at the center; and · safety requirements and procedures in part 9555.9720. Rule Violated: Minnesota Rules, part 9555.9690, subpart 3. 9. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide in-service training annually as required.
· areas related to care of persons, including provision of medication assistance; and · review of parts 9555.9600 to 9555.9730.
SERVICE AND PROGRAM VIOLATIONS 10. Violation: The license holder did not offer services as required. The license holder failed to maintain a record indicating the menu for all meals served for at least six months. Rule Violated: Minnesota Rules, part 9555.9710, subpart 1. SERVICE AND PROGRAM VIOLATIONS 11. Violation: The license holder did not ensure safety as required. The license holder failed to ensure equipment and furniture was in good repair, including: · a ceiling tile in the men’s restroom with water stains; and · stained and dirty carpet throughout the center. Rule Violated: Minnesota Rules, part 9555.9710, subpart 7. YOUR RIGHT TO APPEAL You have the right to appeal the revocation. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. 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. Please send it 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 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 Attention: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked. Legal representation at the contested case hearing: You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Operating the program pending the outcome of the appeal: If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of persons served by your program could result in the immediate suspension of your license. If you continue to operate pending the outcome of your appeal, in addition to the compliance with all applicable statutes and rules, you must comply with the following conditions: 1. You must notify current persons receiving services and all payer sources of this Order of License Revocation. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. The notification must specify the reasons your license was revoked, and it must include a copy of the Order of License Revocation. You must comply with the following deadlines: · Within 20 days of the date of this Order of License Revocation, you must receive approval of the draft of your notice from your licensor. · Within 30 days of the date of this Order of License Revocation, you must notify current persons receiving services and payer sources of the Order of License Revocation. · Within 40 days of the date of this Order of License Revocation, you must submit a list of the individuals and parties that received the notice to your licensor. Submissions required as part of this term must be sent to your Licensor: 1. by secure email at: Alexandra.Devick@state.mn.us; or 2. send fax to: 651-431-7673 ATTN: Alexandra Devick 2. As of the date of this order, you may not: · admit new participants to your program; · increase the hours or days of operation of your program; or · increase the capacity of your program. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license. · The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b). · If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b). · Minnesota Statutes, section 626.557, subdivision 9c, paragraph (d), when substantiated maltreatment is determined to have been committed by an individual who is also the facility license holder, both the individual and the facility must be determined responsible for the maltreatment. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years. · Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked. Questions If you have any further questions regarding this matter, you may contact Brittany Raddatz, Supervisor, at 651-431-6591. Sincerely,
Christala Culhane, Unit Manager Licensing Division Office of Inspector General
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