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September 13, 2022 Lensa Mohamed, Authorized Agent Open Arms Corp 14835 Dallara Avenue Rosemount, Minnesota 55068 License Number: 1076264 (Rule 223) CORRECTION ORDER Dear Lensa Mohamed: On September 7, 2022, a licensing review of Open Arms Corp, located at 624 East Lake Street, 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). The licensing review was limited to review of Minnesota Rules, part 9555.9600 through 9555.9640, 9555.9660 through 9555.9670, and 9555.9690 through 9555.9730 due to the license holder maintaining personnel records and requirements at a different location. 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.14, subdivision 14, paragraph (c). Violation: The license holder did not meet the requirements for attendance record documentation. The license holder failed to maintain documentation of actual attendance for each adult day service recipient for which the license holder was reimbursed by a governmental program that included: · the first, middle, and last name of the recipient; · the time of day that the recipient was dropped off; and · the time of day that the recipient was picked up. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019 and November 29, 2016. Corrective Action Ordered: Immediately, you must maintain documentation as required in this subdivision. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For three of 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 P3 as part of P1 and P3’s initial individual program plan or service plan. The license holder maintained IAPPs for P1 and P3 that were not dated; therefore, the date the IAPPs were developed was unable to be determined. b. The license holder failed to review P1, P2, and P3’s IAPPs quarterly as part of the review of the program plan or service plan. · The license holder maintained an IAPP for P1 that was not dated; therefore, it was unable to be determined whether reviews of P1’s IAPP were completed. · The license holder maintained documentation that P2’s IAPP was most recently reviewed on March 9, 2016. · The license holder maintained and IAPP for P3 that was not dated; therefore, it was unable to be determined whether review of P3’s IAPP were completed. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019. Corrective Action Ordered: At the time of the licensing review, P1 had been discharged; therefore, no corrective action is required for P1. Within 30 days of receiving this order, you must: · review P2 and P3’s IAPP with P2 and P3’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 onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and P3), 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 that included: o P1's source of referral; and o the name and telephone number of the secondary person to call in case of an emergency involving P1; · 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, that included: o a report on a physical examination, updated annually; o a medical history of P1; o indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to P1; o a release signed by the physician indicating whether P1 may engage in a structured exercise program; and o documentation that P1 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · attendance and participation reports and progress notes that are recorded at least monthly; · notes on special problems or on changes needed in medication and on the need for medication assistance; and · a discharge summary. b. The license holder failed to include the following information in P2’s record: · a medical report that included a report on a physical examination, updated annually in 2019, 2020, 2021, and 2022; and · attendance and participation reports and progress notes that are recorded at least monthly. c. The license holder failed to include the following information in P3’s record: · an application form that included P3’s living arrangement, telephone number, and source of referral; · 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; o a medical history of P3; 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 P3 may engage in a structured exercise program; and o documentation that P3 was free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants; · P3’s service agreement with the center, that specified the responsibilities of P3 and the center with respect to payment for and provision of services and signed by P3 or P3’s caregiver and the center director; · notes on special problems or on changes needed in medication and on the need for medication assistance; and · a statement signed by the center director and P3 at the time of admission specifying the basis on which P3 was determined to be capable or incapable of taking appropriate action for self-preservation under emergency conditions. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019 and November 29, 2016. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain: · a discharge summary in P1’s record; and · the information detailed above in P2 and P3’s records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For two participants whose records were reviewed (P1 and P3), the license holder did not complete initial service planning as required. a. The license holder failed to conduct a needs assessment for P1 within 30 days of P1’s admission. The license holder maintained a needs assessment for P1 that was not dated; therefore, the date the needs assessment was conducted was unable to be determined. Additionally, the license holder failed to conduct a needs assessment for P1 that included §P1's physical status, determined by observation, from the intake screening interview, and from the medical report received from P1's physician. b. The license holder failed to: · conduct a needs assessment for P3 that included P3’s physical status, determined by observation, from the intake screening interview, and from the medical report received from P3’s physician. The license holder maintained a needs assessment for P3 dated March 7, 2021; however, there was no medical report in P3’s record; and · develop a preliminary service plan for P3 that included P3’s nutritional needs and, where applicable, dietary restrictions. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019. Corrective Action Ordered: At the time of the licensing review, P1 had been discharged; therefore, no corrective action is required for P1. Within 30 days of receiving this order, you must conduct a needs assessment and preliminary service plan for P3 that includes the information detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 3. 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. The license holder failed to develop written plans of care for P1, P2, and P3 that included§: · an update of the preliminary service plan and additional services required by the participant; · short and long term objectives for the participant 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 review and quarterly revisions of the individual plan of care. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019. §Corrective Action Ordered: At the time of the licensing review, P1 had been discharged; therefore, no corrective action is required for P1. Within 30 days of receiving this order, you must: · develop written plans of care for P2 and P3 that include the information listed above; · 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 30 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 subpart. 6. Citation: Minnesota Rules, part 9555.9650, item B. Violation: For three consultants whose records were reviewed, the license holder did not include all required information in the personnel record. a. The license holder failed to maintain documentation that the registered nurse met any licensure, registration, or certification requirements required to perform services. b. The license holder failed to maintain a copy of a signed contract or letter of appointment specifying conditions and terms of employment for registered dietician and physical therapist. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019. § Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain documentation that your registered nurse meets licensure, registration, and certification requirements required to perform the services specified in the contract; and · maintain a copy of a signed contract or letter of appointment with your registered dietician and physical therapist specifying conditions and terms of employment. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this item. 7. Citation: Minnesota Rules, part 9555.9710, subpart 3, 4, and 7. Violation: The license holder did not offer services as required. a. The license holder failed to offer health services and ensure a registered nurse provided consultation and review of the health services at least monthly. b. The license holder failed to ensure a physical therapist provided consultation and review of the exercise program at least quarterly. c. The license holder failed to maintain family and social histories in P1, P2, and P3’s records that were updated annually. The license holder maintained documentation of P1, P2, and P3’s family and social histories that was not dated; therefore, the it was unable to be determined if P1, P2 and P3’s family and social histories were updated annually. Repeat Violation: You were cited for a similar violation in a Correction Order DHS issued on February 4, 2019 and November 29, 2016. § Corrective Action Ordered: At the time of the licensing review, P1 had been discharged; therefore, no corrective action is required for P1. Within 30 days of receiving this order, you must: · ensure your registered nurse provides consultation and review of your health services; · ensure your physical therapist provides consultation and review of your exercise program; and · review P2 and P3’s family and social histories and update P2 and P3’s family and social histories, if applicable. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in these subparts. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder maintained three different policies and procedures related to suspected or alleged maltreatment. None of the policies and procedures met the requirements of this section; therefore, the license holder failed to establish policies and procedures related to suspected or alleged maltreatment that: · met all the requirements identified for the optional internal reporting policies and procedures in section 626.557, subdivision 4a; · identified the primary and secondary person or position to whom internal reports may be made and the primary and secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5. The secondary person must be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; · ensured that an internal review was completed within 30 calendar days and that corrective action was taken as necessary to protect the health and safety of vulnerable adults when the facility had reason to know that an internal or external report of alleged or suspected maltreatment had been made. The review must include an evaluation of: o whether related policies and procedures were followed o whether the policies and procedures were adequate; o whether there is a need for additional staff training; o whether the reported event is similar to past events with the vulnerable adults or the services involved; and o whether there is a need for corrective action by the license holder to protect the health and safety of vulnerable adults; · based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or the license holder, if any; · identified the primary and secondary person or position who will ensure that, when required, internal reviews are completed. The secondary person shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and · document and make internal reviews accessible to the commissioner immediately upon the commissioner's request. Corrective Action Ordered: Immediately, you must ensure the policy and procedures listed above are established as required in this subdivision. A copy of the policies and procedures must be posted in a prominent location in the program. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: The license holder did not establish a written program abuse prevention plan (PAPP) as required. The license holder failed to establish a written PAPP, including: · an assessment of the population, including: o the need for training of staff to meet identified individual needs; and o the knowledge a license holder may have regarding previous abuse that is relevant to minimizing risk of abuse for clients; · an assessment of the physical plant where the licensed services are provided, including: o the condition and design of the building as it related to the safety of the persons; and o the existence of areas in the building which are difficult to supervise; and · an assessment of the environment, including the type of grounds and terrain surrounding the building. Corrective Action Ordered: Within 30 days of receiving this order, you must establish a written PAPP as detailed above. A copy of the PAPP must be posted in a prominent location in the program. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Rules, part 9555.9720, subparts 7, 8, and 9. Violation: The license holder did not ensure safety as required. a. The license holder failed to ensure equipment and furniture was in good repair, including: · a restroom sink with exposed plywood; · exercise equipment that was stacked with miscellaneous items, such as rugs, blankets, and cushions; · exercise equipment that was missing pieces such as handles; and · a missing ceiling tile in a restroom. b. The license holder failed to ensure the areas used by participants were free from debris, loose plaster, peeling paint, and litter, including: · a broken baseboard trim that exposed peeling paint and plaster; · loose toilet paper on restrooms floors; · stacked debris and litter, including discarded coffee cans, water jugs, and office supply boxes, throughout program spaces; · sticky condiment substances on tiled floor that is used by participants; and · spiders and cobwebs throughout the center. c. The license holder failed to have written plans for emergencies caused by fire that included: · identification of primary and secondary exits; · identification of building evacuation routes; · identification of an emergency shelter area within the center; · procedures for the quarterly fire drill; and · instructions on location of fire extinguishers. Corrective Action Ordered: Immediately, you must: · ensure all equipment and furniture used by participants is in good repair; · ensure all areas used by participants are free from debris, peeling paint, and litter; and · develop written plans for emergencies caused by fire that include the information detailed above. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subparts. 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 ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Brittany Raddatz, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6591
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