|
February 12, 2026 Abu Munye, Authorized Agent Comfort Senior Center 2523 Portland Avenue Apartment 1509 License Number: 1119801 (Rule 223) CORRECTION ORDER Dear Abu Munye: On January 22, 2026, a licensing review of Comfort Senior Center located at 806 East Franklin 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 2. Violation: For one of three participants whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder did not review P1’s IAPP with their interdisciplinary team, at least annually in 2025. Corrective Action Ordered: Within 30 days of receiving this order, you must review P1’s IAPP with their interdisciplinary team. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For one participant whose record was reviewed (P2), the license holder did not include information in the participant’s written record as required. The license holder did not include a medical report in P2’s record, dated within three months prior to or 30 days after P2’s admission to the center. P2 was admitted to the center on March 12, 2025 and the license holder maintained a medical report for P2 dated May 13, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 3. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not complete initial service planning as required. The license holder did not conduct a needs assessment for P2 and P3 that addressed the participant’s physical status using information from the medical report received from the participant’s physician. · The license holder conducted P2’s needs assessment on March 12, 2025. The license holder did not receive the medical report from P2’s physician until May 13, 2025. · The license holder conducted P3’s needs assessment on September 1, 2025. The license holder did not receive the medical report from P3’s physician until November 18, 2025. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For two participants whose records were reviewed (P2 and P3), the license holder did not develop a written plan of care as required. The license holder did not develop written plans of care for P2 and P3 that included short and long term objectives for P2 and P3 stated in concrete, measurable, and time specific outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P2 and P3 that include short and long term objective stated in concrete, measurable, and time specific outcomes; · complete an audit of all participants’ written plans of care to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained; and · for participants who do not have a written plan of care that includes all required information, you must develop a plan detailing how your program will maintain a complete written plan of care within 60 days of receiving this order. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For one consultant whose records was reviewed, the license holder did not include all required information in the personnel record. The license holder did not maintain a current copy of a signed contract or letter of appointment specifying conditions and terms of employment for the registered dietician. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain a current copy of a signed contract or letter of appointment as detailed above in the personnel record for the registered dietician. On an ongoing basis, you must maintain compliance as required in this item. 6. Citation: Minnesota Rules, part 9555.9710, subparts 1 and 7. Violation: The license holder did not offer services as required. a. The license holder did not maintain a current and accurate contract with their food service provider that prepared food off-site. The license holder maintained a contract that expired on May 31, 2024. b. The license holder did not maintain a family and social history in P1’s record that was updated annually in 2025. The license holder maintained documentation that P1’s family and social history was most recently reviewed in December 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain a current and accurate contract with a food service provider; and · document the review of P1’s family and social history and update P1’s family and social history, if applicable. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9720, subpart 9.
The license holder did not post emergency plans in a visible place in the center. Corrective Action Ordered: Within 30 days of receiving this order, you must post your emergency plans in a visible place in the center. On an ongoing basis, you must maintain compliance as required in this subpart. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a).
Violation: The license holder did not establish and enforce their program abuse prevention plan (PAPP) as required. The license holder failed to ensure the license holder’s governing body or the governing body’s delegated representative reviewed the PAPP at least annually.
Corrective Action: Within 30 days of receiving this order, you must have your governing body, or the governing body’s delegated representative, review the PAPP and document the review of the 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. Kristopher Oberg, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-6589
|
