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April 29, 2025 Debesay Girmalul, Authorized Agent Comfort Adult Daycare LLC 1201 37th Avenue North License Number: 1092616 (Rule 223) CORRECTION ORDER Dear Debesay Girmalul: On February 12, 2025, a licensing review of Comfort Adult Daycare LLC located at 1821 University Avenue West, Saint Paul, 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 (c) and subdivision 2, paragraph (a). Violation: For one of four participants whose record was reviewed (P1), 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 P1 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. P1 was admitted on July 1, 2024, and the license holder maintained documentation that the orientation was provided on July 11, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P1-P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). a. The license holder failed to develop an IAPP for P2 as part of P2’s initial individual program plan or service plan. b. The license holder failed to review P1-P4’s IAPPs quarterly as part of the review of the program plan or service plan. c. The license holder failed to review P3 and P4’s IAPPs with P3 and P4’s interdisciplinary teams, at least annually, using the individual assessment and any reports of abuse relating to the person.
· review P1, P3, and P4’s IAPPs quarterly as part of the review of the program plan or service plan; · review P3 and P4’s IAPP annually with P3 and P4’s interdisciplinary teams and document the review; · complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and · for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For four participants whose records were reviewed (P1-P4), 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 and P2’s participant records: · a medical report, dated within the three months prior to or 30 days after P1 and 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 indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1 and P2; o a release signed by the physician indicating whether P1 and P2 may engage in a structured exercise program; and o documentation that P1 and P2 were free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants. · participation reports and progress notes that are recorded at least monthly; and · notes on special problems, medication changes, and need for medication assistance. b. The license holder failed to include the following information in P3’s participant record: · a medical report, dated within the three months prior to or 30 days after P3’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, updated annually in 2025; o a medical history of the person; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P3; o a release signed by the physician indicating whether P4 may engage in a structured exercise program; and o documentation that P4 were free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; and · notes on special problems, medication changes, and need for medication assistance. c. The license holder failed to maintain participation reports and progress notes for P4 that were recorded at least monthly. Repeat Violation: In a Correction Order that DHS issued on May 26, 2022, you were previously found in violation of this same rule. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1-P3), the license holder did not complete initial service planning as required. The license holder failed to conduct a needs assessment for P1-P3 within 30 days of P1-P3’s admission to the center that included; · P1-P3’s psychosocial status (for example, awareness level, personal care needs, need for privacy or socialization); · P1-P3’s functional status (for example, endurance and capability for ambulation, transfer, and managing activities of daily living); and · P1-P3's physical status, determined by observation, from the intake screening interview, and from the medical report received from P1-P3's physicians. Repeat Violation: In a Correction Order that DHS issued on May 26, 2022, you were previously found in violation of this same rule. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For four participants whose records were reviewed (P1-P4), 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-P3 within 90 days of admission to the center that included: · an update of the preliminary service plan and additional services required by P1-P3; · short and long term objectives for P1-P3 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 P4 that included provisions for quarterly reviews and quarterly revisions of the individual plan of care. Repeat Violation: In a Correction Order that DHS issued on May 26, 2022, you were previously found in violation of this same rule. 6. Citation: Minnesota Rules, part 9555.9650, item A and B. Violation: For two of two staff persons (SP1 and SP2) and one consultant 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 in SP1 and SP2’s personnel record in 2024. 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 physical therapist’s personnel record.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete a performance evaluation for SP1 and SP2 and maintain documentation of the evaluation in SP1 and SP2’s personnel record; and · maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment for your physical therapist 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. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual review to a mandated report as required. The license holder failed to provide SP1 and SP2 annual review in 2024 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 (PAPP), and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.
8. Citation: Minnesota Rules, part 9555.9690, subpart 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide in-service training annually as required. The license holder failed to provide SP1 and SP2 a minimum of eight hours of in-service training annually in 2024 in areas related to care of center participants, including provision of medication assistance and review of parts 9555.9600 to 9555.9730.
9. Citation: Minnesota Rules, part 9555.9710, subparts 3, 4, 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 ensure the registered physical therapist provided consultation and review of the exercise program, at least quarterly in 2024. c. The license holder failed to maintain a family and social history for P4 that was updated annually in 2025. Repeat Violation: In a Correction Order that DHS issued on May 26, 2022, you were previously found in violation of this same rule. 10. 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 the governing body or the governing body’s delegated representative reviewed the PAPP as least annually in 2023 and 2024, using the assessment factors in the plan; and any substantiated maltreatment findings that occurred since the last review. The license holder maintained documentation that their PAPP was most recently reviewed in December, 2022.
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
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