Hope Harbor

Violation cited by DHS

The license holder’s written program descriptions, and policies and procedures that implement the program described, did not meet requirements. The descriptions suggest that participating in and attending spiritual and religious components and activities of the program is required, and that lack thereof, is considered as a basis for privileges in the facility. Residents and staff reported this to be their understanding as well. Additionally, the offering of alternative programming components and activities described by the license holder during the onsite licensing review were not included in the program descriptions or policies and procedures.

Violation cited by DHS

The license holder’s plan for transfer of clients and records upon closure did not meet requirements for the transfer of closed case records in the following ways: a. The plan did not include either a signed agreement or other documentation indicating that a county or similarly licensed provider has agreed to accept and maintain the program’s closed case records if the organization closes; and b. The plan included a statement that the license holder would maintain client records for up to one year, however, Minnesota Statutes, section 245A.041, subdivision 3, requires a license holder to maintain all records related to the licensed program, including client records, for five years from the date of closure.

Violation cited by DHS

The license holder’s grievance procedure did not meet requirements in the following ways: a. It did not indicate that upon receiving a compliant, the license holder would give the person who wants to make a grievance, the necessary forms to file the grievance; and b. It did not include that a person filing a grievance would receive a response within five days from the initial date of the compliant.

Violation cited by DHS

The license holder’s annual training plan did not meet requirements. The plan did not include how the license holder determines the amount of training that is needed for a volunteer based upon the position description, tasks to be performed, and the performance indicators of the position, including the amount of in-service training per year for a volunteer consistent with their duties and directly related to the needs of children in their care.

Violation cited by DHS

An internal review for a report of alleged or suspected maltreatment of a minor, dated October 2, 2023, was not completed within 30 calendar days from when the report was made.

Violation cited by DHS

The license holder did not provide for the safe storage and delivery of medications. The license holder allowed for over-the-counter medications to be administered to residents without a written order by a prescribing physician.

Violation cited by DHS

In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement. Personnel Files

Violation cited by DHS

Two of five personnel files reviewed for requirements governing the provision of background studies did not meet requirements in the following ways: a. As a result of a licensing review, a DHS Licensor determined that the license holder failed to submit a background study before an adult, regardless of whether the individual will have direct contact with persons served by the children’s residential facility, began working in the facility or setting and allowed for the staff person to have access to people served by the program before a BGS notice was issued: i. SP1 began working in a children’s residential facility on August 19, 2024, however, the license holder did not submit a BGS request to DHS for SP1 until August 24, 2024, and a BGS notice was not issued until August 31, 2024. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), except for BGS violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a BGS violation before the commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a BGS violation may not avoid a fine for a subsequent BGS violation unless at least 365 days have passed since the license holder self-corrected the earlier BGS violations. Because the license holder self-corrected the ...

Violation cited by DHS

One of two personnel files reviewed governing annual training (personnel file numbered 4) did not meet requirements. Training was not completed annually, for calendar years 2023 and 2024, to the following: a. Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; b. All internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults receiving services; and c. The license holder’s program abuse prevention plan (PAPP).

Violation cited by DHS

One of three resident files reviewed for requirements governing the administration of medication (resident file numbered 1) did not meet requirements in the following ways: a. The license holder did not document and follow the prescribing physician’s directions for monitoring medications used by the resident in the following ways: i. A medication change was noted on the medication administration record (MAR) in the month of August 2024, however, there was not an order for the medication change in the resident’s file; ii. The directions for administering a medication on the resident’s MAR did not match the physicians order, dated July 12, 2024, for the time of the day the medication was to be administered; and b. The records for a resident who receives prescription drugs at the facility did not meet requirements in the following ways: i. In the month of June 2024, medications were documented to have been given on a date that the resident had not been in admittance to the program and there was no documentation to demonstrate medications were administered on a day the resident was identified as present in the facility; and ii. In the month of August 2024, a medication appeared to have been documented as given, however, there was a line drawn through with no notes indicating if the medication was administered or not.

Violation cited by DHS

In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement.

Violation cited by DHS

One resident file reviewed governing discharge requirements (resident file numbered 3) did not meet requirements. The license holder did not document the inventory of the property returned to the resident at discharge to demonstrate any discrepancies between the admission inventory and the discharge inventory.