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April 21, 2025 Sahra Mohmoud, Authorized Agent Nicollet Adult Center Inc 2614 Nicollet Avenue South Suite 100 Minneapolis, Minnesota 55408 License Number: 1116161 (Rule 223) CORRECTION ORDER Dear Sahra Mohmoud: On April 10, 2025, a licensing review of Nicollet Adult Center Inc located at 2614 Nicollet 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 9555.9600, subpart 1. Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not include in formation in the participant’s written record as required. a. The license holder failed to include an application form in P1’s record that included the name and telephone number of P1’s physician or medical provider. b. The license holder failed to include the following information in P2’s record: · an application form that included: o P2’s telephone number; and o the name and telephone number of the person to call in case of emergency involving the person and name and number of another person to call if that person cannot be reached. Repeat Violation: In a Correction Order that DHS issued on November 27, 2024, you were previously found in violation of this same subpart. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain all information detailed above in P1 and P2’s record. On an ongoing basis, you must maintain compliance as required in this subpart. 2. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For one of two staff persons (SP1) 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 2024. SP1 was hired in April 2023. b. The license holder failed 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. 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 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. 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. Desiree Tiller, HCBS Licensor Licensing Division Office of Inspector General 651-431-4622
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