February 3, 2023                  CERTIFIED MAIL

Lensa Mohamed, Authorized Agent

Open Arms Corp

14835 Dallara Avenue

Rosemount, Minnesota 55068

License Number: 1076264 (Rule 223)

ORDER OF CONDITIONAL LICENSE

Dear Lensa Mohamed:

The Department of Human Services (DHS) is placing your license to provide adult day care at Open Arms Corp, 624 East Lake Street, Minneapolis, Minnesota on conditional status for two years, beginning February 3, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with adult day care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

On September 7, 2022, DHS licensors conducted a licensing review at your facility located at 624 East Lake Street, Minneapolis, Minnesota. As a result of this licensing visit, DHS determined that your program failed to comply with the laws and rules that apply to licensed adult day centers. As a result of that licensing review a correction order was issued, dated September 13, 2022, citing ten violations.

On December 8, 2022, a follow-up licensing review was made to your facility. DHS determined that you had not complied with the corrective action ordered in the correction order dated September 13, 2022. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program.

· Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include:

o Failure to ensure safety;

o Failure to maintain attendance record documentation;

o Failure to maintain participants’ written records;

o Failure to complete initial service planning;

o Failure to develop written plans of care;

o Failure to maintain personnel records;

o Failure to provide training to mandated reporters;

o Failure to provide staff orientation to the center;

o Failure to provide staff annual in-service training;

o Failure to offer services;

o Failure to establish policies and procedures related to suspected or alleged maltreatment; and

o Failure to establish a program abuse prevention plan (PAPP).

· Chronicity: Your program received its license on June 11, 2015. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history:

o November 29, 2016 Correction Order:      20 violations

o February 4, 2019 Correction Order:      15 violations (8 repeat)

o September 13, 2022 Correction Order:      10 violations (7 repeat)

o December 9, 2022 Temporary Immediate Suspension:   Imminent risk of harm to persons

served

o February 3, 2023 Conditional License (this order):   13 violations (9 repeat)

· Severity: Many of the violations that led to the Order of Conditional license relate to the health and safety of persons served.

Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide adult day services is placed on a conditional status.

Licensing Violations

DHS determined that your program failed to follow licensing rules and statutes, as described below.

SAFETY VIOLATIONS

1. 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; and

· exercise equipment that was stacked with miscellaneous items, such as rugs, blankets, and cushions.

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; and

· rodent droppings on restroom floors.

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.

Rule Violated: Minnesota Rules, part 9555.9720, subparts 7, 8, and 9.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: 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.

Within 10 days of receiving this order, you must:

· submit an inspection from a professional pest control company to your licensor; and

· complete each recommendation from the professional pest control company.

Within 30 days of receiving this order, you must submit evidence to your licensor of the completion of each recommendation from the professional pest control company. On an ongoing basis, you must maintain compliance as required in these subparts.

PARTICIPANT RECORD VIOLATIONS

2. 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.

Statute Violated: Minnesota Statutes, section 245A.14, subdivision 14, paragraph (c).

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately, you must maintain documentation as required in this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision.

3. Violation: For three of 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 a discharge summary in P1’s record.

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; 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 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; and

· notes on special problems or on changes needed in medication and on the need for medication assistance.

Rule Violated: Minnesota Rules, part 9555.9660, subpart 1.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: 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.

On an ongoing basis, you must maintain compliance as required in this part.

4. Violation: For one participant whose record was reviewed (P3), the license holder did not complete initial service planning as required.

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.

Rule Violated: Minnesota Rules, part 9555.9700, subpart 2.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Within 30 days of receiving this order, you must conduct a needs assessment for P3 that includes the information detailed above. On an ongoing basis, you must maintain compliance as required in this subpart.

5. Violation: For two participants whose records were reviewed (P2 and P3), 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 P2 that included§:

· an update of the preliminary service plan and additional services required by P2;

· short and long term objectives for P2 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.

b. The license holder failed to develop a written plan of care for P3 that included§:

· an update of the preliminary service plan and additional services required by P3;

· 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.

Rule Violated: Minnesota Rules, part 9555.9700, subpart 3.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Within 30 days of receiving this order, you must develop written plans of care for P2 and P3 that include the information listed above. On an ongoing basis, you must maintain compliance as required in this subpart.

PERSONNEL RECORD VIOLATIONS

6. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain a personnel record as required.

a. The license holder failed to maintain the following in SP1’s personnel record:

· SP1’s job description; and

· documentation of an annual performance evaluation.

b. The license holder failed to maintain the following in SP2’s personnel record:

· SP2’s job description;

· an employment application or resume indicating that SP2 met the requirements in part 9555.9680, subpart 2; and

· documentation of an annual performance evaluation.

Rule Violated: Minnesota Rules, part 9555.9650, item A.

Corrective Action Required: Within 30 days of receiving this order, you must:

· maintain job descriptions in SP1 and SP2’s personnel records;

· maintain an employment application or resume in SP2’s record; and

· complete performance evaluations for SP1 and SP2 and maintain documentation of the evaluations in the staff person’s personnel record.

On an ongoing basis, you must maintain compliance as required in this item.

7. 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 the registered dietician and physical therapist.

Rule Violated: Minnesota Rules, part 9555.9650, item B.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: 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.

On an ongoing basis, you must maintain compliance as required in this item.

8. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation and annual review to a mandated reporter as required.

a. 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 PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact.

b. The license holder failed to provide SP1 and SP2 annual review to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, the license holder's PAPP, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3.

Corrective Action Required: Immediately, you must provide the required orientation and annual review detailed above to SP1 and SP2. On an ongoing basis, you must maintain compliance as required in this subdivision.

9. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide orientation to the center as required.

The license holder failed to provide SP2 with 20 hours of orientation to the center within the employee’s first 40 hours of employment at the center, including:

· at least four hours of supervised orientation before SP2 worked directly 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.

Rule Violated: Minnesota Rules, part 9555.9690, subpart 3.

Corrective Action Required: Within 30 days of receiving this order, you must provide the required orientation training detailed above to SP2. On an ongoing basis, you must maintain compliance as required in this subpart.

10. 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 areas related to care of center participants, including provision of medication assistance, and review of parts 9555.9600 to 9555.9730

Rule Violated: Minnesota Rules, part 9555.9690, subpart 4.  

Corrective Action Required: Within 30 days of receiving this order, you must provide the required in-service training detailed above to SP1 and SP2. On an ongoing basis, you must maintain compliance as required in this subpart.

SERVICE AND PROGRAM VIOLATIONS

11. 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.

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 P2 and P3’s records that were updated annually. The license holder maintained documentation of P2 and P3’s family and social histories that were not dated; therefore, it was unable to be determined if P2 and P3’s family and social histories were updated annually.

Rule Violated: Minnesota Rules, part 9555.9710, subparts 3, 4, and 7.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: 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.

On an ongoing basis, you must maintain compliance as required in these subparts.

POLICY AND PROCEDURES VIOLATIONS

12. 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.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b).

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: 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. On an ongoing basis, you must maintain compliance as required in this subdivision.

13. 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.

On December 8 and 9, 2022, DHS licensors observed packed snow and ice on the exterior walkway and entrance to the center. As a result of the license holder’s failure to assess the type of grounds and terrain surrounding the building, the license holder failed to include statements of the specific measures that would be taken to keep the exterior walkway free from snow and ice or other unsafe conditions.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2.

Repeat Violation: In a Correction Order that DHS issued on September 13, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Within 30 days of receiving this order, you must establish and enforce a written PAPP as detailed above. A copy of the PAPP must be posted in a prominent location in the program. On an ongoing basis, you must maintain compliance as required in this subdivision.

Corrective action required

You must correct the violations as described above. If you fail to demonstrate substantial compliance with adult day care requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license.

CONDITIONAL LICENSE TERMS

In addition to the adult day care licensing rules and statutes, you are required to comply with the following terms:

1. Within 15 days of receiving this order, you must notify current persons receiving services, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request.

While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving adult day care services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request.

Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. Additionally, while the license is on conditional status, you must maintain documentation of the names of individuals you’ve provided the notification to and the date the individual was provided the notification.

2. Within 30 days of receiving this order, you must:

· develop a quality assurance audit tool to ensure personnel records include all required documentation and training;

· develop a quality assurance audit tool to ensure participant records include all required information; and

· submit the quality assurance audit tools to your DHS licensor for approval.

3. Within 30 days of receiving approval of your quality assurance audit tools from your DHS licensor, you must complete an audit of all participant and personnel records using the approved quality assurance audit tool. Additionally, you must submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit.

4. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Prior to admitting any new participant during the duration of the conditional license, you must notify your licensor of the name and admission date of the new participant.

Submissions required as part of a corrective action ordered must be sent to your Licensor:

1. by secure email at: Brittany.Raddatz@state.mn.us; or

2. send fax to:

651-431-7673

ATTN: Brittany Raddatz

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

· Clearly state that you are requesting reconsideration of the conditional license

· List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· State why you believe your license should not be on a conditional status

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Conditional license stayed pending reconsideration

If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all adult day care laws and rules.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· Adult day care centers are required to follow Minnesota Statutes, chapters 245A and 245C and Minnesota Rules, parts 9550.9600 to 9555.9730.

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4.

· If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4.

· Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6544.

Sincerely,

Jill Slaikeu, HCBS Unit Manager

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/