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April 22, 2025 Nimu Hersi, Authorized Agent Active Adult Day Center LLC 12700 Nicollet Avenue Apartment 223 Burnsville, Minnesota 55378 License Number: 1118903 (Rule 223) CORRECTION ORDER Dear Nimu Hersi: On April 16, 2025, a licensing review of Active Adult Day Center located at 4062 West County Road 42, Savage, 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 9555.9660, subpart 1. Violation: For two of two participants whose records were reviewed (P1 and P2), the license holder did not include information in the participant’s written record as required. The license holder failed to include a medical report in P1 and P2’s record, dated within the three months prior to or 30 calendar days after the participants admission to the center. · P1 was admitted to the center on July 22, 2024, and the license holder maintained a medical report for P1 on January 24, 2025. · P2 was admitted to the center on October 1, 2024, and the license holder maintained a medical report for P2 on January 13, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 2. 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’s admission date was July 22, 2024. The license holder failed to: · conduct a needs assessment for P1 that addressed P1’s physical status using information from the medical report received from the participant’s physician. The license holder conducted P1’s needs assessment on July 22, 2024, but did not receive the medical report from P1’s physician until January 24, 2025; and · develop a preliminary service plan for P1 within 30 days of P1’s admission. The license holder maintained a preliminary service plan that was not dated; therefore, the date the preliminary service plan was developed was unable to be determined. Additionally, the license holder failed to develop a preliminary service plan for P1 that included P1’s nutritional needs and dietary restrictions. P1’s medical report stated P1 has a “low carb, low fat” diet; however, this information was not included in P1’s preliminary service plan. b. The license holder failed to conduct a needs assessment for P2 that addressed P2’s physical status determined from the medical received from P2’s physician. The license holder conducted a needs assessment for P2 on October 1, 2024, but did not receive the medical report from P2’s physician until January 13, 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must: · update P1 and P2’s needs assessments to include the participant’s physical status based on information received from the medical report; and · update P1’s preliminary service plan to include the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. The license holder had food prepared off-site but failed to maintain a current contract with the food service provider. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a current contract with a food service provider. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9650, items A and B. Violation: For one of two staff persons (SP2) and two consultants whose records were reviewed, the license holder did not maintain a personnel record as required. a. The license holder failed to maintain a job description in SP2’s personnel record. b. The license holder failed to include a copy of a signed contract or letter of appointment specifying conditions and terms of employment in the physical therapist and registered dietician’s personnel record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a job description in SP2’s personnel record; and · maintain a copy of a signed contract or letter of appointment with your physical therapist and registered dietician specifying conditions and terms of employment. On an ongoing basis, you must maintain compliance as required in these items. 5. Citation: Minnesota Rules, part 9555.9690, subpart 2. 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. SP1 had CPR training on December 11, 2024, and the first admission to the center was on July 22, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to a mandated reporter as required. 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 program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving service within 72 hours of first providing direct contact. Corrective Action Ordered: Immediately, you must provide SP2 with the orientation to the reporting requirements detailed above. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9555.9690, subpart 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation to the center as required. The license holder failed to provide SP1 and SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including: · at least 4 hours of supervised orientation 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 Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with the required orientation training detailed above. On an ongoing basis, you must maintain compliance as required in this subpart.
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. Kristopher Oberg, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6589
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