facility_name: Bridge for Youth (The)

report_date: October 24, 2023

raw_content:
October 24, 2023 La’Kisha Hollmon-Griffin

License Number: 830857 (Shelter & Trans)

CORRECTION ORDER

Dear La’Kisha Hollmon-Griffin,

On September 25 through 28, 2023 the Department of Human Services (DHS) conducted a licensing review of The Bridge For Youth, located at  to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, transitional services under Minnesota Rules, part 2960.0500, and shelter program services under Minnesota Rules, parts 2960.0510 through 2960.0530. As a result of this licensing review a Correction Order is being issued.

The program units reviewed were as follows:

· Gloria’s Place: Shelter program serving youth with children

· Marlene’s Place: Transition program serving youth with children

· Resilience House: Shelter program

LICENSING VIOLATIONS

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

RESIDENT FILES

1. Violation: Two of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident files numbered 1 & 2). The resident file did not have a signed receipt of property upon discharge.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of discharge procedures meets all applicable requirements.

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

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 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 20 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

Legal authority for this licensing action

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

· This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960.

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6259. Sincerely,

Katie Leuer, Unit Supervisor 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/


state: MN

facility_name: Brooklyn Avenues

report_date: January 25, 2023

summary: CORRECTION ORDER

raw_content:
January 25, 2023

Katherine Meerse, Authorized Agent

1708 Oak Park Ave N

Minneapolis, MN 55411

RE:  Report No. 202206416

Brooklyn Avenues

License No. 1076492 (CRF)

Dear Mrs. Meerse:

CORRECTION ORDER

An investigation of Brooklyn Avenues located at 7210 76th Ave N Brooklyn Park, MN 55428 was completed regarding report number 202206416 which alleged violation of Minnesota Statutes, section 626.557, and Minnesota Rules, parts 2960.0010 through 2960.0050 This maltreatment allegation concerned sexual abuse. The disposition of the investigation report is inconclusive. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

The following violation of state and (or) federal laws and rules were observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violation within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

Citation: Minnesota Statutes, section 245A.65, subdivision 3; and Minnesota Rules, part 2960.0100, subpart 3, item A.

Violation: The license holder failed to provide annual training on the Reporting of Maltreatment of Vulnerable Adults Act to one staff person (P).

Corrective Action Ordered: On an ongoing basis you must maintain compliance with this licensing requirement throughout the program.

If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Ginny Benson at (651) 431-6957.

Sincerely,

Kim Anderson, Senior Investigator

Office of Inspector General

Licensing Division

kyle.youker@state.mn.us

651-431-4056

Enclosure

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

doc_type: Correction Order


raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”

Report Number: 202206416

Date Issued: January 25, 2023

Name and Address of Facility Investigated:

Brooklyn Avenues
7210 76th Ave N
Brooklyn Park, MN 55428

Disposition: Inconclusive

License Number and Program Type:

1076492-CRF (Children’s Residential Facility)

Investigator(s):

Kimberly Anderson/Kyle Youker
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-4056

Suspected Maltreatment Reported:

It was reported that a staff person (SP) embraced a vulnerable adult (VA) in a tight hug and rubbed the VA’s genitals.  The next day the SP touched the VA inappropriately again and kissed the VA on the lips.

Date of Incident(s): August 5 and August 6, 2022

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c):

Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast.

Summary of Findings:

Pertinent information for this investigation was obtained during a site visit conducted on August 31, 2022; documentation from the facility and law enforcement records; and through three interviews conducted with the VA, the supervisory staff person (P), and the SP.

The facility provided shelter and housing options for youth between the ages of sixteen and twenty-four who were experiencing homelessness.

Facility documentation showed that on July 28, 2022, the VA was admitted to the facility. The VA provided information at that time that s/he was diagnosed with autism spectrum disorder, anxiety, and depression. The VA’s strengths were staying positive, discussing healthy coping mechanisms, and living his/her “truth.” The VA’s goals included having better eating habits, making friends, and being consistent with his/her therapy. The VA was not subject to guardianship.

The VA provided the following information:

· The VA described the SP as someone who worked “mostly” on the weekends cooking, cleaning, and providing supervision to the residents. The SP consistently asked the VA about what the VA liked and did not like which made the VA feel “suspicious.” The VA said that s/he frequently visited with the SP alone in the office to “have someone to talk to” because s/he felt the SP “favored me.” The VA described being favored by the SP as the SP “seemed to like me.”

· At an unknown time, on the evening of August 5, 2022, the VA was in his/her bedroom while the SP was doing room checks. The SP knocked on the VA’s door and asked if the VA was “okay.” The VA did not initially respond, so the SP asked a second time. The SP then entered the VA’s bedroom and asked the VA, “What’s going on?” The SP then told the VA, “Come here,” and the SP hugged the VA for about one and a half minutes.

· The VA stated that at one point during the hug the SP “grazed” the VA’s genitals and made a facial expression as if it was an accident. The SP then asked the VA if s/he was hungry, and the VA said, “Yes.” The SP then drove to and purchased McDonald’s. The SP then told the VA that s/he “really liked me.”

· On August 6, 2022, at approximately 6 a.m. the VA awoke from having a “surreal nightmare” and began screaming. The SP entered the VA’s room and asked if the VA was “okay.” The VA went with the SP to the staff office where the SP closed the door and “came in for a hug again.”

· The VA said that the SP told the VA, “Don’t tell anyone.” The SP then took a mask the VA was wearing off the VA and put it into the VA’s hooded sweatshirt. The SP kissed the VA on lips once and touched the VA’s “upper body.” The SP attempted to kiss the VA a second time but the VA turned his/her head to avoid the kiss. The VA stated that the SP “got the sign I am not interested” and the VA left the staff office and went into the facility kitchen. The VA could not tell if the SP’s touching was sexual in nature. All of the touching by the SP was done over the VA’s clothing. At some point, the VA told his/her sibling about the incident and the sibling told the VA that the VA should tell someone at the facility. The VA then told the P about the incidents.

The Critical Incident Reporting Form written by the P stated that on August 5, 2022, the VA reported an interaction between the SP and the VA made the VA “feel unsafe.” The SP was doing room checks and SP hugged the VA “grazed” the VA’s genitals. On August 6, 2022, the VA had a nightmare so the SP invited the VA to the staff office where at some point kissed the VA on the lips once. The SP attempted to kiss the VA a second time but the VA moved his/her head away to avoid the second kiss. The VA then left the staff office and went to the kitchen. While in the kitchen, the VA heard the SP coming so the VA went into his/her bedroom and locked the door.

The P said that when s/he learned of the incident, s/he went to the facility and checked the cameras. There was a camera in the staff office, however the location in which the incident occurred was out of frame of the camera. At some point the P, talked to the SP and when the topic of the incident between the SP and the VA was brought up the SP “seemed confused, but not shocked.”

An interview with the SP provided the following information:

· The SP did not have much interaction with the VA other than occasionally making him/her food. The SP stated that s/he was only in the VA’s bedroom on one occasion when the window was broken and the SP attempted to fix it. The SP denied hugging the VA, touching the VA’s leg, and/or removing the mask from the VA and kissing the VA on the lips.

· Later in the interview the SP provided conflicting information saying that s/he hugged the VA in the staff office after the VA had a “bad dream.” The SP then stated that s/he massaged the hand of the VA because the VA had a “muscle cramp.” The SP also massaged the shoulders of the VA because the VA “looked tired.” The SP denied massaging the VA’s leg or genital area. The SP and the VA were in the staff office between 10 to 15 minutes before the VA left the office. The SP denied that s/he had sexual intent regarding massaging the VA.

The SP interviewed with law enforcement in the presence of his/her significant other. The SP provided information to law enforcement that was consistent with the information that s/he provided to this investigator. The SP “insisted the allegations against him/her were false” and denied kissing the VA.

Facility documentation shows that all staff persons interviewed, including the SP, were trained on the facility’s policies and the Reporting of Maltreatment of Vulnerable Adults Abuse Act. Facility documentation shows the SP was last trained on June 18, 2021, which was a violation of Minnesota Statutes, section 245A.65, subdivision 3; and Minnesota Rules, part 2960.0100, subpart 3, item A which states in part that the license holder shall ensure that mandated reporters receive annual training on the reporting of maltreatment requirements.

Conclusion:

The VA stated that the SP hugged the VA, grazed the VA’s genitals, kissed the VA one time, and touched the VA’s “upper body”. The VA also stated that when the SP grazed the VA’s genitals, the SP made a facial expression as if it was an accident and that s/he could not tell if the SP’s touching was sexual in nature.

The SP provided conflicting information regarding hugging the VA. The SP initially denied hugging the VA but then stated that s/he did hug the VA. The SP also said that s/he massaged the VA’s hand and shoulders because the VA was stressed and had “muscle cramps” but denied that it was done with sexual intent and denied kissing the VA.

Given the conflicting information provided between the VA and the SP, that there was no information to support or refute either account, there was not a preponderance of the evidence whether the SP’s actions were intentional or done with sexual or aggressive intent.

It was not determined whether sexual abuse occurred (sexual contact is defined as any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast).

Action Taken by Facility:

The facility conducted an internal review and determined that the SP touched the VA both with a back massage and a hand massage. The facility determined that all policies and procedures were adequate and followed, and there was no need to retrain staff persons. The SP no longer worked at the facility.

Action Taken by Department of Human Services, Office of Inspector General:

On January 25, 2023 the facility was issued a Correction Order for the violation outlined in this report.

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

doc_type: Maltreatment Finding


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

doc_type: Document


facility_name: Divine Intervention

report_date: November 15, 2023

raw_content:
November 15, 2023                  CERTIFIED MAIL

Aretta-Rie Johnson, Authorized Agent

DIVINE Institute

838 Stellar Place

St. Paul, MN 55117

License Number 1081329 (CRF)

ORDER TO PAY A FINE

Dear Aretta-Rie Johnson:

The Department of Human Services (DHS) is ordering you to pay a fine of $100 for one licensing violation at your children’s residential facility located at 806 Edmund Ave, St. Paul, MN 55104. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

The license holder failed to comply with the Settlement Agreement effective on July 12, 2022, term #3, paragraph d. The license holder failed to submit the quarterly results of the monthly self-monitoring reviews for July, August, and September 2023 due no later than October 15, 2023.

Fine: $100

Corrective Action Required: Immediately and on an ongoing basis through the duration of the settlement agreement, the license holder must ensure compliance with the terms of the settlement agreement. Within 10 days of receipt of this order, submit documentation of the results of the monthly self-monitoring for July, August, and September 2023 as detailed in the terms of the settlement agreement.

Statute Violated: Minnesota Statute, section 245A.06, subdivision 3.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated:

· March 2, 2023;

· May 3, 2023; and

· August 28, 2023

Billing and Payment of the Fine

DHS will send you an invoice for the $100 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is personally and jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

YOUR RIGHT TO APPEAL

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive this order. Please send it 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

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $100 fine for each occurrence of a licensing violation that is not related to health, safety, supervision, or maltreatment under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(v).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

Questions

If you have any further questions regarding this matter, you may contact Paula Halverson, Manager, at 651-431-5653.

Sincerely,

Paula Halverson, 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/

doc_type: Notice of Violation


report_date: October 4, 2023

raw_content:
October 4, 2023

Aretta-Rie Johnson

DIVINE Institute

838 Stellar Place

St. Paul, MN 55117

License Number: 1081329 (CRF)

CORRECTION ORDER

Dear Aretta-Rie Johnson,

On September 26, 2023, a modified licensing review of DIVINE Intervention, located at 806 Edmund Ave, St, Paul, MN 55104, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and shelter care services for children under Minnesota Rules, parts 2960.0510 through 2960.0530. 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 an applicant or 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 applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing review and licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Practice

1. Citation: Minnesota Statues, section 245A.06, subdivision 3.

Violation: The license holder failed to comply with the Settlement Agreement effective on July 12, 2022, term #3, paragraph a (resident files numbered 1 and 2). The resident files did not contain a copy of the notice with resident and legal representative(s) signature. Through a review of resident files it was determined the license holder failed to notify new residents and referral sources of the settlement agreement and the reasons the license is subject to the settlement agreement prior to admission.

Corrective Action Ordered: Immediately and on an ongoing basis through the duration of the settlement agreement, the license holder must ensure compliance with the terms of the settlement agreement.

Repeat Violation: The license holder was cited for a similar violation in correction orders dated

· March 2, 2023;

· May 3, 2023; and

· August 28, 2023

Personnel Files

2. Citation: Minnesota Rules, part 2960.0150, subpart 2.

Violation: One personnel file was reviewed for requirements governing professional licensure (personnel file numbered 1) and did not meet requirements. The file did not contain documentation that the staff professional licensure is current.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure professional licensure meets all applicable requirements.

3. Citation: Minnesota Rules, parts 2960.0100, subpart 3, item B and 2960.0150, subpart 4, item D.

Violation: One personnel file was reviewed for the requirement governing ongoing training (personnel file numbered 1) and did not meet requirements. The file did not contain documentation the staff was trained on the following:

a. Ongoing training that must help staff meet the needs of residents and must include skills development; and

b. Sufficient training to competently care for residents. The amount of training must be provided at least a ratio of one hour of training for each 50 hours worked.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for ongoing training that demonstrates compliance.

4. Citation: Minnesota Rules, part 2960.0080, subpart 14.

Violation: One personnel file was reviewed for requirements governing emergency procedures (personnel file numbered 1) and did not meet requirements. The file did not contain documentation the staff was trained on emergency procedures annually in calendar year 2023.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure emergency procedures meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for emergency procedures that demonstrates compliance.

Resident Files

5. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B.

Violation: One of two resident files reviewed for requirements governing resident admission documentation (resident file numbered 1) did not meet requirements. The file did not contain documentation of the placing agency’s case plan goals for the resident.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident admission documentation meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022 and correction order dated March 2, 2023.

6. Citation: Minnesota Rules, part 2960.0050, subpart 3, item A.

Violation: One of two resident files reviewed for requirements governing basic rights information (resident file numbered 1) did not meet requirements. The file did not contain documentation the resident was given a written copy of the resident’s basic rights information within 24 hours of admission.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure basic rights information meets all applicable requirements.

7. Citation: Minnesota Rules, parts 2960.0520, subpart 2, items A and B.

Violation: One resident file reviewed for requirements governing shelter programs (resident file numbered 1) did not meet requirements. The file did not contain documentation the following was completed within 24 hours of the resident’s admission:

a. The license holder did not arrange for a qualified professional to conduct a basic health screen to determine if the resident needed a physical or dental examination by a medically licensed person; and

b. The license holder did not assess the resident’s vulnerability to maltreatment and develop a plan to reduce the resident’s risk of maltreatment while in the shelter.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure shelter programs meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for one resident for shelter programs that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022 and correction order dated March 2, 2023.

8. Citation: Minnesota Rules, part 2960.0520, subpart 3.

Violation: One resident file reviewed for requirements governing plan for immediate needs (resident file numbered 1) did not meet requirements. The file did not contain documentation the license holder developed a plan for meeting the resident’s immediate needs within 24 hours of admission.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure plan for immediate needs meets all applicable requirements.

9. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (c).

Violation: Three of three resident files reviewed for requirements governing trauma informed care (resident files numbered 1 through 3) did not meet requirements. The file did not contain documentation the license holder completed a screen for trauma by completing a trauma-specific screening tool with the youth upon the youth’s admission or obtain the results of a trauma-specific screening tool that was completed with the youth within 30 days prior to the youth’s admission to the program.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma informed care meets all applicable requirements. Within 30 days of receipt of this correction order, submit documentation of trauma informed care that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in correction order dated March 2, 2023.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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.

Submissions required as part of a corrective action ordered must be sent to Ginny Benson

1. By secure email to: ginny.benson@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Ginny Benson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF Senior Licensor

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/


raw_content:
May 3, 2023

Aretta-Rie Johnson

DIVINE Institute

838 Stellar Place

St. Paul, MN 55117

License Number: 1081329 (CRF)

CORRECTION ORDER

Dear Aretta-Rie Johnson,

A correction order is being issued as a result of failure to follow terms of a settlement agreement as required under Minnesota Statutes 245A.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or 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 applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing review and licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Practice

1. Citation: Minnesota Statues, section 245A.06, subdivision 3.

Violation: The license holder failed to comply with the Settlement Agreement effective on July 12, 2022, term #3, paragraph d. The license holder failed to submit the quarterly results of the monthly self-monitoring reviews for January, February, and March 2023 due no later than April 15, 2023.

Corrective Action Ordered: Immediately and on an ongoing basis through the duration of the settlement agreement, the license holder must ensure compliance with the terms of the settlement agreement. Within 10 days of receipt of this order, submit documentation of the results of the monthly self-monitoring for January, February, and March 2023 as detailed in the terms of the settlement agreement.

Repeat Violation: The license holder was cited for a similar violation in correction order dated March 2, 2023.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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.

Submissions required as part of a corrective action ordered must be sent to Ginny Benson

1. By secure email to: ginny.benson@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Ginny Benson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF Senior Licensor

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/


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March 2, 2023

Aretta-Rie Johnson

DIVINE Institute

838 Stellar Place

St. Paul, MN 55117

License Number: 1081329 (CRF)

CORRECTION ORDER

Dear Aretta-Rie Johnson,

On January 18 and 19, 2023, a modified licensing review of DIVINE Intervention, located at 806 Edmund Ave, St, Paul, MN 55104, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and shelter care services for children under Minnesota Rules, parts 2960.0510 through 2960.0530. 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 an applicant or 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 applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing review and licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Practice

1. Citation: Minnesota Statues, section 245A.06, subdivision 3.

Violation: The license holder failed to comply with the Settlement Agreement effective on July 12, 2022, term #3, paragraph a. Through a review of resident files and discussion with the license holder, it was determined the license holder failed to notify new residents and referral sources of the settlement agreement and the reasons the license is subject to the settlement agreement.

Corrective Action Ordered: Immediately and on an ongoing basis through the duration of the settlement agreement, the license holder must ensure compliance with the terms of the settlement agreement. Within 30 days of receipt of this order, submit documentation all current residents and referral sources have been notified of the settlement agreement as detailed in the terms of the settlement agreement.

Personnel Files

2. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: One personnel file was reviewed for requirements governing safe storage and delivery of medications (personnel file numbered 1) and did not meet requirements. The file did not contain documentation of the specific medication assistance training provided by the registered nurse. In addition, the formalized training required additional supplemental medication administration demonstration by the nurse.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the safe storage and delivery of medications meets all applicable requirements. Within 30 days of receipt of this order, submit documentation staff (personnel file numbered 1) has been trained to provide medication assistance that demonstrates compliance.

3. Citation: Minnesota Rules, part 2960.0100, subpart 3, item A.

Violation: One file was reviewed for the requirement governing orientation (personnel file numbered 1) and did not meet requirements. The file did not contain documentation the staff was trained on disability needs of families served prior to having unsupervised direct contact with residents.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

Resident Files

4. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B.

Violation: One of three resident files reviewed for requirements governing resident admission documentation (resident file numbered 1) did not meet requirements. The file did not contain documentation of the spiritual or religious affiliation of the resident and the resident’s family.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident admission documentation meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

5. Citation: Minnesota Rules, part 2960.0160, subpart 2, items A and C.

Violation: One resident file was reviewed for the requirements governing the license holder’s ability to meet the resident needs (resident file numbered 3) and did not meet requirements. The file did not contain documentation whether the resident was a danger to the resident’s self or others and whether the program is able to meet the residents’ cultural, emotional, educational, mental health and physical needs.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure documentation of the ability to the meet the resident needs meets all applicable requirements.

6. Citation: Minnesota Rules, parts 2960.0520, subpart 2, item B; and 2960.0070, subpart 5, item C.

Violation: Two of three resident files reviewed for requirements governing health screening did not meet requirements in the following ways:

a. Within 24 hours of admitting the resident, the license holder did not arrange for a qualified professional to conduct a basic health screen to determine if the resident needed a physical or dental examination by a medically licensed person (resident file numbered 2);

b. Documentation did not include notification to the resident’s case manager of the need to make an appointment with a medically licensed person to follow up on a resident’s vision (resident files numbered 2); and

c. Documentation did not include if the health screen occurred within 24 hours of admission (resident file numbered 3).

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the health screening meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

7. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D.

Violation: Two of two resident files reviewed for requirements governing educational services (resident files numbered 1 and 3) did not meet requirements. The file did not contain documentation the license holder provided education about chemical health to the resident who had a problem related to inappropriate chemical use, but who does not have sufficient chemical use history to refer to treatment.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure educational services meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for one resident that demonstrates compliance.

8. Citation: Minnesota Rules, parts 2960.0020, subpart 42; and 2960.0180, subpart 2, item B

Violation: One resident file reviewed for requirements governing treatment plans (resident file numbered 3) did not meet requirements. The treatment plan did not include the following:

a. Identified goals and objectives of treatment and treatment strategy;

b. A schedule for accomplishing treatment goals and objectives;

c. The individuals responsible for providing treatment; and

d. A designated staff person who was assigned to the resident to ensure regular face-to-face contact and to monitor and assist the resident to implement the treatment plan.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure treatment planning meets all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan for one resident that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022

9. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: One of two resident files reviewed for requirements of safe storage and delivery of medications (resident file numbered 3) did not meet requirements. The file did not contain the following documentation:

a. The license holder contacted a newly admitted resident’s pharmacy to verify the following information regarding prescribed medication:

1. Instructions about how the medication must be administered;

2. The symptoms that the medication will alleviate; and

3. The symptoms that would warrant consultation with the physician.

b. The amount of medication given, dosage, and time when the medication was taken.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the safe storage and delivery of medications that meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

10. Citation: Minnesota Rules, part 2960.0530, subpart 2.

Violation: One resident file was reviewed for requirements governing shelter 30-day review (resident file numbered 1) and did not meet requirements. The review did not review the need for the resident to remain in the shelter program and alternative placement plans considered.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure shelter 30-day review meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for one resident file that demonstrates compliance.

11. Citation: Minnesota Rules, part 2960.0090, subpart 2.

Violation: One resident file was reviewed for requirements governing no eject discharge (resident file numbered 2) and did not meet requirements. The file did not contain documentation of the following:

a. The license holder conferred with other interested persons to review the issues involved in the decision to discharge;

b. Whether additional strategies to resolve the issues leading to discharge could have been developed to allow the resident an opportunity to continue to receive services; and

c. The reason for discharge and the alternatives considered or attempted when the decision to discharge was warranted.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure no eject discharge meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

12. Citation: Minnesota Rules, parts 2960.0190, subparts 1, item A and 2; and 2960.0520, subpart 2, item C.

Violation: One resident file was reviewed for requirements governing discharge documentation (resident file numbered 1) and did not meet requirements. The file did not contain the following documentation:

a. A transition service plan that was developed prior to the resident’s release from the program;

b. The transition service plan did not include the following:

1. Identify resources available in the community to address the resident’s continuing needs after release from the facility;

2. Consideration of the environment into which the resident will return, and recommendations of how to deal with issues or potential challenges within that environment.

c. The extent to which the resident’s stay in the facility met the goals and objectives of the resident’s treatment plan including the following:

1. Identify which services, including education, were provided directly or indirectly to the resident; and

2. Identify the services, including education, that were recommended in the resident’s case plan or treatment plan but were not provided to the resident.

d. The name and address of the party the resident was released to following discharge.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure discharge documentation meets all applicable requirements. Submit documentation for one resident that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in an order of conditional license dated April 27, 2022.

13. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (c).

Violation: One of three resident files reviewed for requirements governing trauma informed care (resident file numbered 2) did not meet requirements. The file did not contain documentation the license holder completed a screen for trauma by completing a trauma-specific screening tool with the youth upon the youth’s admission or obtain the results of a trauma-specific screening tool that was completed with the youth within 30 days prior to the youth’s admission to the program.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma informed care meets all applicable requirements.

14. Citation: Minnesota Statutes, section 245A.25, subdivision 5, paragraph (d).

Violation: Three of three resident files reviewed for requirements governing residential settings specializing in providing care and supportive services for youth who have been or are at risk of becoming victims of sex trafficking or commercial sexual exploitation (resident files numbered 1 through 3) did not meet requirements. The file did not contain documentation the license holder offered a trafficking prevention education curriculum.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure residential settings specializing in providing care and supportive services for youth who have been or are at risk of becoming victims of sex trafficking or commercial sexual exploitation meets all applicable requirements. Within 30 days of receipt of this correction order, submit documentation of a plan that demonstrates compliance.

Repeat Violation: The license holder was cites for a similar violation in an order of conditional license dated April 27, 2022.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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.

Submissions required as part of a corrective action ordered must be sent to Ginny Benson

1. By secure email to: ginny.benson@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Ginny Benson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF Senior Licensor

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/


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PUBLIC

Summary of Settlement Agreement

License Holder: D.I.V.I.N.E. Institute

License Number: 1081329

Program Type: Children’s Residential Facility (CRF)

Date of Licensing Action: April 27, 2022

Licensing Action Taken: Order of Conditional License

Reconsideration requested and settlement agreement signed by Commissioner on:

July 12, 2022

Terms of Settlement Agreement:

Conditional license not imposed; license holder operating pursuant to terms of settlement agreement.

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

doc_type: Order


raw_content: April 27, 2022 CERTIFIED MAIL Aretta-Rie Johnson, Authorized Agent DIVINE Institute 14785 262nd Ave NW Zimmerman, MN 55398 License Number: 1081329 (Children’s Residential Facility) ORDER OF CONDITIONAL LICENSE Dear Aretta-Rie Johnson: The Department of Human Services (DHS) is placing your license to provide services at DIVINE Intervention, 806 Edmund Avenue, St. Paul, MN, 55104, on conditional status for two years, beginning May 10, 2022. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Children’s Residential Facilities 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, March 5 through 10, 2022 a DHS licensor conducted a licensing review at your facility located at 806 Edmund Avenue, St. Paul, MN, 55104. As a result of this licensing visit, the DHS licensor determined that your program failed to comply with the laws and rules that apply to licensed children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120; group residential settings under Minnesota Rules, parts 2960.0130 through 2960.0220; and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 citing 26 violations. 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 and Severity: · Failed to provide services at a licensed residential facility (citation numbered 1); · Failed to provide a reasonable degree of privacy (citations numbered 1 and 2); · Failed to provide adequate staffing (citations numbered 3); · Failed to ensure resident’s right to courteous and respectful treatment (citation numbered 4); · Failed to have a medically licensed person provide consultation and review of the administration of medications at least monthly (citation numbered 5); · Failed to maintain the safe storage and delivery of medications (citation numbered 6 and 7); · Failed to initiate a background study for a staff person (citation numbered 8); · Failed to provide adequate orientation training (citation numbered 10); · Failed to provide adequate ongoing training (citations numbered 11 and 12); · Failed to obtain consent from legal authority for placement (citation numbered 13); · Failed to provide a resident orientation to maltreatment of vulnerable adults (citation numbered 15); · Failed to meet the requirements of a resident health screen upon admission (citation numbered 16); · Failed to meet treatment plan requirements (citation numbered 17); and · Failed to follow discharge and aftercare requirements, including a transition service plan (citation numbered 20) Due to the nature and severity of these violations of not following through with requirements in the program, which impact the health and safety of persons served in your care, your license to provide children’s residential facilities services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: The license holder failed to follow the corrective action ordered for citation numbered one in a Correction Order issued on July 12, 2019. The license holder provided residential services at an unlicensed facility (the “Annex”) in addition to those provided at the licensed program located at 806 Edmund Avenue. Documentation showed all current residents spent the night at the Annex on December 3, 2021. During interviews, residents reported they spent the night at the Annex on average twice monthly. Staff person (SP5) states the overnights occur less frequently, once every few months. Documentation dated November 15, 2021, stated resident (R4) “is staying with SP5,” and “with SP5,” An interview with the SP5 on March 29, 2022, confirmed R4 spent the night at the Annex with the SP5. A Correction Order dated July 12, 2019, required the license holder to immediately cease the programmatic use of the Annex for overnight sleeping. SP5 stated during an interview on March 29, 2022, they disregarded the corrective action ordered in the correction order to be able to use the Annex in this way and continued to use the Annex despite the corrective action ordered. Through interviews with both residents and SP5, it was determined residents from the license holder’s foster residence setting license number 1107952, would spend the night with the residents from Divine Intervention program when having sleepovers at the Annex. All residents slept in one common space, the sanctuary, with no separate sleeping quarters. Guardians were not informed of the overnights, did not give consent for the overnights, and were unaware both programs were doing overnights together at the Annex. The Annex location did not meet the following requirements: a. It is unknown if the facility’s location, offices, and other structures conformed to applicable health, fire, zoning, and building codes; b. It is unknown if the facility’s plumbing, ventilation, heating, cooling, lighting, and other fixtures and equipment conformed to the applicable health, sanitation, and safety codes and regulations; c. There was no statement of intended use describing how the facility was to be used; and d. The staffing plan did not address staffing at the Annex location. During the licensing review, the license holder was ordered to immediately cease the use of the Annex for overnight sleeping. Rule and Statute Violated: Minnesota Statutes, section 245A.06, subdivision 3; and Minnesota Rules, parts 2960.0020, subpart 44; 2960.0030, subpart 2, item B; 2960.0050, subpart 1, item B; 2960.0100, subpart 1; and 2960.0210, subparts 1 and 2 Repeat Violation: In a Correction Order that DHS issued on July 12, 2019, you were previously found in violation of these rules/statutes. 2. Violation: The license holder failed to ensure that R1 had a reasonable degree of privacy. Documentation showed R1 spent the night at the foster residence setting, license number 1107952, on December 29, 2021, with SP5. In an interview with SP5 on March 29, 2022, it was confirmed the overnight at the foster residence setting occurred. It was also reported during the interview SP5 and R1 each slept in a separate reclining chair in the main living room, not allowing for private sleeping quarters. SP5 confirmed the resident’s guardian was not informed of the offsite overnight prior to it occurring and that the guardian did not give consent. Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item B 3. Violation: The license holder failed to provide at a minimum, one staff person per 25 residents to be present and awake at all times in the facility when residents are normally asleep. a. On December 29, 2021, SP5 confirmed they were the only staff on shift and slept during the overnight; and b. During interviews with residents, licensor determined a SP5 did not remain awake for the entirety of the overnight(s) at the Annex. The license holder’s approved staffing plan states a staff member will remain awake at all times. Rule Violated: Minnesota Rules, part 2960.0150, subpart 3, item G 4. Violation: The license holder failed to ensure the resident’s right to courteous and respectful treatment was protected. The license holder required each resident to pick a new nickname prior to admission, and the use of a nickname was mandatory, regardless of individual preference. During their admission, each resident was addressed by this nickname instead of their legal name. During the on-site licensing review, a DHS Licensor observed a staff person using a resident’s nickname, and upon request, the staff person was unable to identify the resident’s legal name. Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item N 5. Violation: The license holder failed to ensure that a medically licensed person provided consultation and review of the administration of medications at least monthly. The license holder was unable to provide any documentation to demonstrate that the consultation and review occurred and could not articulate the process. Information obtained in an interview indicated the review had not been completed for at least six months. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D 6. Violation: Four of four resident files reviewed for requirements governing the safe storage and delivery of medications did not meet requirements in the following ways: a. The license holder failed to maintain a record of illness reported by the resident and the action taken by the license holder (R5); b. The license holder failed to contact a newly admitted resident’s prescribing medically licensed person to verify the following information regarding prescribed medications (R1, and R4 through R6): 1. Instructions about how the medication must be administered; 2. The symptoms that the medication will alleviate; and 3. The symptoms that would warrant consultation with the physician. The license holder has a variance to contact the pharmacy that filled the prescription rather than the prescribing physician to verify the items listed above. However, through conversation with the license holder, the license holder was unware of this requirement or that they had a variance to contact the pharmacy. Through an interview with the nurse, the nurse stated they believed the program director verified all medications upon admission. The nurse also confirmed they themselves did not review medication orders or verify medications upon admission; c. The license holder did not obtain, or attempt to obtain, guardian permission for the facility to administer medications (R5). The license holder obtained consent from the resident’s county child protection worker but not the resident’s parents who were guardians; d. The license holder failed to maintain a record of the quantity of medication initially received from the pharmacy (R1, and R4 through R6); e. The medication administration record (MAR) did not document whether or not the medication was given or refused; the MAR was blank on the following dates: 1. December 9, 2021; December 15, 2021; December 30, 2021; January 15, 2022; and January 29, 2022 (R1); 2. October 26, 2021; December 9, 2021; December 13, 2021; and December 15, 2021 (R4); 3. February 17, 2022 (R6). f. The license holder failed to obtain resident specific orders for over-the-counter medications administered to R6 on March 2, 2022, and to R5 on an unknown date. · The license holder confirmed that the program does not having resident specific orders for over-the-counter medications. · During an interview with SP4, they stated they had recommended to the license holder they obtain standing orders for each resident in the past. However, SP4 had not reviewed files to determine if resident specific orders for over-the-counter medications had been obtained or followed up with the license holder after the conversation. · During an interview with R5, the resident indicated he/she was administered Tylenol and Ibuprofen from staff. Resident file contained no documentation of resident specific orders for medications. g. The medication administration record documented that the resident was “on hold” when they were out of the facility overnight, and there was no documentation to demonstrate the following medications were administered: 1. Guanfacine on December 29, 2021, at bedtime and December 30, 2021, in the morning and at bedtime (R1); and 2. Quetiapine, Fluoxetine and a pre-natal vitamin on November 15, 2021 at bedtime and November 16, 2021 in the morning (R4); Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items B, D, and E 7. Violation: The license holder’s plan for the safe storage and delivery of medicine did not address the following required components: a. The need to obtain resident specific orders for over-the-counter medications; and b. The process of holding medications or how medications were to be administered when the resident was away from the facility overnight. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D 8. Violation: One of three personnel files reviewed for requirements governing the initiation of background studies did not meet requirements (SP4). The license holder failed to initiate a background study for a staff person before they began in a position allowing direct contact with children served by the program (SP4). The staff person was initially employed through a nursing agency that provided nursing services to the program but became an independent contractor on May 1, 2019. The license holder did not initiate a background study when the staff person became an independent contractor. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g) 9. Violation: One personnel file reviewed for requirements governing the documentation requirements for a person working in a children’s residential facility and did not meet requirements (SP1). The license holder failed to document the date SP1 began working in the facility. Statute Violated: Minnesota Statutes, section 245A.041, subdivision 5 10. Violation: Two of two personnel files reviewed for requirements governing orientation (SP1 and SP2) did not meet requirements in the following ways: a. There was no documentation to demonstrate staff were oriented to the following: b. Gender issues, including the psychosocial development of boys and girls; 1. Sexual orientation issues; and 2. Physical, mental, sensory, and health-related disabilities, bias, and discrimination. c. Orientation to the following was not completed prior to having unsupervised contact with residents: 1. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues; and 2. General and special needs, including disability needs, of residents and families served. Rule Violated: Minnesota Rules, parts 2960.0100, subpart 3, item A; and 2960.0150, subpart 4, item C 11. Violation: Two of two personnel files reviewed for requirements governing ongoing training (SP3 and SP4) did not meet requirements. There was no documentation to demonstrate that the following required training was provided in 2021: a. Vulnerable reporting requirements and definitions; b. The program abuse prevention plan; and c. Adult maltreatment Internal and external policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245A.65, subdivision 3; and Minnesota Rules, part 2960.0100, subpart 3 12. Violation: Two of three personnel files reviewed for requirements governing emergency procedures (SP3 and SP4) did not meet requirements. There was no documentation to demonstrate the emergency plan was reviewed with the staff at least once every six months in 2021. Rule Violated: Minnesota Rules, part 2960.0080, subpart 14 13. Violation: Two of three personnel files reviewed for requirements governing the documentation of training did not meet requirements. Training provided in calendar year 2021 and 2022, the resident file did not consistently document the following: a. The name of the entity that provided the training (SP2); and b. The number of hours of in-service training completed (SP4). Rule Violated: Minnesota Rules, part 2960.0100, subpart 5 14. Violation: Three of four resident (R) files reviewed for requirements governing resident admission documentation did not meet requirements. The file did not contain the following documentation upon or within 5 working days after admission: a. The license holder failed to obtain consent from the legal authority for the resident’s placement (R5). The license holder obtained consent from the resident’s county case manager instead of R5’s parents who were the legal guardians; b. The resident file did not document the resident’s time of admission (R1 and R3); and c. The resident file did not document the placing agency’s case plan goal (R3). Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B 15. Violation: One of four resident files reviewed for requirements governing basic rights information (R5) did not meet requirements. The license holder did not tell the resident’s parent, guardian, or custodian within a reasonable time after admission to the facility that the information on resident’s basic rights is available. The license holder informed the county case manager but did not inform the resident’s parents. Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item B 16. Violation: One file reviewed for requirements governing vulnerable adult orientation (R4) did not meet requirements. There was no documentation to demonstrate the resident was oriented to the following within 24 hours of turning 18 or 72 hours for persons who would benefit from a later orientation: a. The internal and external reporting policies, including the telephone number for the Minnesota Adult Abuse Reporting Center; and b. The program abuse prevention plan. Statute Violated: Minnesota Statutes, section 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a) 17. Violation: Three of three resident files reviewed for requirements governing health screenings did not meet requirements in the following ways: a. The health screen did not include the following: 1. The name of the resident’s most recent physician (R1 and R5); 2. Clinic name (R5); 3. Clinic address (R1 and R5); 4. Clinic phone number (R1 and R5). b. The health screen was not completed within 24 hours of admission (R5). The resident began services on January 7, 2022 and the health screen was not completed until January 20, 2022; and c. The file did not contain documentation the health screen was reviewed by a licensed professional in a related field (R4). The resident’s health screen was completed by their County Child Protection Worker. Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items A and C 18. Violation: Three of three resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The treatment plan was not developed within 10 days of admission (R1); b. The treatment plan did not include the following (R1, R4, and R5): 1. A schedule for accomplishing treatment goals; and 2. The entities responsible for providing treatment services to the resident. c. The file did not contain documentation the license holder assigned the resident a designated staff person to ensure regular face-to-face contact and to monitor and assist the resident to implement the treatment plan (R1, R4, and R5); d. The treatment plan’s goals and objectives were not individualized to each resident’s individual needs. All treatment plans had the same or similar goals and language (R1, R4, and R5); and e. The treatment plan was not updated during monthly reviews when progress was made on a goal or no longer applicable to the resident (R1, R4, and R5). Rule Violated: Minnesota Rules, parts 2960.0020, subpart 76; and 2960.0180, subpart 2, item B Repeat Violation: In a Correction Order that DHS issued on July 12, 2019, you were previously found in violation of these rules. 19. Violation: One resident file was reviewed for the requirements governing discharge (R2) and did not meet requirements. The resident’s discharge required the license holder to follow their no-eject policy, but the file did not contain documentation of the following: a. The license holder conferred with other interested persons to review the issues involved in the decision; b. Whether additional strategies to resolve the issues leading to discharge could have been developed to allow the resident an opportunity to continue to receive services; and c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2 20. Violation: Two of two resident files reviewed for requirements governing return of resident’s property (R1 and R3) did not meet requirements. The file did not contain documentation the license holder returned all of the resident’s property to the resident along with a signed receipt upon discharge. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3 21. Violation: Four of four resident files review for requirements governing discharge and aftercare did not meet requirements in the following ways: a. The file did not contain a transition service plan (R1 and R3); b. The transition service plan did not include the following: 1. The plan was not developed prior to the resident’s discharge from the program (R4); 2. Documentation did not include the plan was developed with the placing agency (R4); 3. Recommendations of ways to meet the resident’s needs and identify resources available in the community to address the resident’s continuing needs after release from the program (R4); 4. Consideration of the environment into which the resident will return, and recommend how the resident may deal with issues and potential challenges within that environment (R6); 5. Documentation the plan was developed with input from the resident, the resident’s family members, if appropriate, and the persons who will provide support services to the resident upon release (R6); 6. Documentation a copy of the plan was given to the resident and the residential treatment facility that the resident will attend or is placed in after release (R4 and R6); and 7. Personal safety needs of the resident (R4). c. The license holder did not document the extent to which the resident’s stay in the facility met the goals and objectives of the resident’s treatment plan, including the following: 1. Which services, including education, were provided directly or indirectly to the resident and who provided the services (R1 and R3); and 2. The services, including education, that were recommended in the resident’s case plan or treatment plan but were not provided to the resident (R1, R3, and R4). Rule Violated: Minnesota Rules, parts 2960.0190, subparts 1, items A and B, and 2, items A and B; 2960.0520, subpart 2, item C Repeat Violation: In a Correction Order that DHS issued you were previously found in violation of these same rules in the following orders dated: · July 12, 2019; and · September 12, 2018 22. Violation: Three of three resident files reviewed for the requirements governing residential settings specializing in providing care and supportive services for youth who have been or are at risk of becoming victims of sex trafficking or commercial sexual exploitation did not meet requirements. The file did not contain documentation of the following: a. The license holder offered a trafficking prevention education curriculum (R1, R5, and R6). The license holder stated they contracted with an outside agency to provide “My Life, My Choice” curriculum and provided dates the sessions took place. However, the license holder did not have documentation to support which residents attended or were offered the training; and b. The youth engaged in the discharge planning process (R1 and R6). Statute Violated: Minnesota Statutes, section 245A.25, subdivision 5, paragraph (d) 23. Violation: The license holder’s plan for transfer of clients and records upon closure did not specify the arrangements the program would make to transfer a resident to another provider or county agency for the continuation of services if the program closed. A controlling individual did not annually evaluate the plan for transfer of clients and records upon closure in calendar year 2021. The plan was reviewed and signed on March 1, 2022. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraphs (a) and (b) 24. Violation: The license holder’s 2021 annual evaluation of strengths and weaknesses of the program did not include the following: a. Grievances; and b. The license holder’s goals and progress on those goals. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A 25. Violation: The license holder’s governing body did not review the Program Abuse Prevention Plan at least annually for the period of May 2020 to March 2022 reviewed during the licensing review. The DHS licensor e-mailed the license holder on December 27, 2021 with a list of documentation that would be required to be available on the first day of the licensing review. This was requested again in person on March 7, 2022, the first day of the licensing review, and again on March 8, 2022. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) 26. Violation: The license holder did not meet requirements for community involvement. License holder had not documentation of the following: a. Annual meetings with the board of directors or advisory committee from the review period of May 2020 through March 2022; and b. Annual meetings with community leaders representing the area where the facility is located to advise the community leaders about the nature of the program, the types of residents served, the results of the services the program provided the residents, the number of residents served in the past 12 months; and the number of residents likely to be served in the next 12 months from the review period of May 2020 through March 2022. Rule Violated: Minnesota Rules, part 2960.0060, subpart 6 Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to Katie Leuer within 30 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with children’s residential facilities, group residential services, and shelter services 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. Submissions required as part of a corrective action ordered must be sent to DHS Licensing: 1. By secure email to: katherine.a.leuer@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Katie Leuer Licensing Division PO Box 64242 St. Paul, MN 55164-0242 CONDITIONAL LICENSE TERMS In addition to the children’s residential facilities, group residential serves, and shelter services licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this order, you must notify current residents and all parties who refer residents to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new residents and referral sources the license is on conditional status before they begin receiving treatment services. The notification to new residents must specify the length of time of the conditional status of your 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. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file. Within 45 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice. 2. Within 14 days of receipt of this order, you must submit and obtain approval by DHS a plan on the safe storage and delivery of medications. The plan must be developed in consultation with a medically licensed person and address the following: a. Staff training on administering medications; b. Verifying medications upon admission; c. A practice and documentation of medication errors, including when to report to the nurse; d. Obtaining resident specific medication orders for over the counter medications; e. Documentation of medication administration; f. When to contact the nurse regarding medication and medical concerns; g. Addressing medications needing refills; h. Destruction of medications; i. A monthly review of medication administration. Upon DHS approval, you must provide within 30 days an interactive instructor led training on the plan of the safe storage and delivery of medications to all direct care staff and repeat at a minimum annually. 3. Within 7 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a Children’s Residential Facility training to obtain education and assistance on the rule requirements. Individuals employed as the Chief Executive Officer, Program Director, and Nurse must attend the Children’s Residential training offered by DHS Licensing. Training must be scheduled and completed within 45 days of receipt of this order. 4. Within 45 days of receipt of this order, you must develop a self-monitoring plan for an ongoing approach for monitoring compliance with applicable rules and statues requirements. The self-monitoring plan must include the following: a. Name and title of those responsible to carry out the duties of the plan; and b. A monthly audit of resident records, personnel records and the monitoring for the implementation of all policies and procedures. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies founds within the reviews and corrective actions taken, must be submitted to your licensor on July 15, 2022, Oct 15, 2022, January 15, 2023, April 15, 2023, or until otherwise determined by DHS Licensing. 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 Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 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 Licensing Division Attention: 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 2 years from that date. You continue to be required to comply with all Children’s Residential Facilities laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Children’s Residential Facilities are required to follow children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120; group residential settings under Minnesota Rules, part 2960.0130 through 2960.0220; and shelter care services under Minnesota Rules, part 2960.0510 through 2960.0530. · 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 Paula Halverson, Unit Manager, at 651-431-5653. Sincerely, Paula Halverson, 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/


facility_name: Evergreen Shelter Program

raw_content:
June 20, 2023

Ebony Warren, Authorized Agent Evergreen Shelter Program

License Number: 800759 (CRF)

CORRECTION ORDER

Dear Ebony Warren:

On May 22, 2023, DHS Licensing conducted a full licensing review at your facility, Evergreen Shelter Program, located at  . As a result of this visit, DHS is issuing this order which requires you to take the corrective action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

PERSONNEL FILES

1. Violation: One of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 1). Documentation of orientation for operational policies and procedures of the license holder, including the program’s drug and alcohol policy, was left blank.

Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c), and Minnesota Rules, part 2960.00100, subpart 3, item A

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation documentation meets all applicable requirements.

2. Violation: Two of two personnel files reviewed for requirements governing the provision of ongoing staff training did not meet requirements (personnel files numbered 1 and 3). Documentation did not show that the emergency plan was reviewed every 6 months in the year 2022.

Rule Violated: 2960.0080, Subpart 14

Repeat Violation: In a Correction Order that DHS issued on December 9, 2020, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements.

RESIDENT FILES

3. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 2, and 3). There was no date on the “Client Inventory” document to demonstrate that it was completed upon admission.

Rule Violated: 2960.0070, Subpart 4

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that inventory and handling of resident property meet all applicable requirements.

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

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 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 20 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

Legal authority for this licensing action

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

· This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960.

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6259. Sincerely,

Katie Leuer, Unit Supervisor 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/


facility_name: Get It Right

raw_content:
PUBLIC

Summary of Settlement Agreement

License Holder: Get It Right, Inc

License Number: 1125400

Program Type: Children’s Residential Facility

Date of Licensing Action: March 24, 2026

Licensing Action Taken: Order of License Revocation

Action appealed and settlement agreement signed by Commissioner on: May 19, 2026

Terms of Settlement Agreement:

DHS will not impose Order of License Revocation if License Holder complies with terms for Settlement Agreement. One controlling individual removed from license. Program can operate.

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


facility_name: Grafton Integrated Health Network Minnesota Psychiatric Residential Tr

report_date: January 24, 2025

raw_content:
January 24, 2025                  CERTIFIED MAIL

Tony Sanders, Authorized Agent

Grafton Integrated Health Network Minnesota

3150 Shawnee Dr.

Winchester, VA 22601

License Number: 1109203 (PRTF)

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATION

Dear Tony Sanders:

The Department of Human Services (DHS) is ordering you to pay a fine of $200 for 2 background study violations. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order based on your failure to comply with the following background study requirement:

Background Study Violation Determined on December 2, 2024:

1. As a result of a licensing review, a DHS licensor determined that you failed to request a background study (BGS) for two staff persons (SP1 and SP2) 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.

a. SP1 began working in a children’s residential facility on February 26, 2024: however, the license holder did not submit a BGS request to DHS for SP1 until April 24, 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 background study violation involving SP1 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP1.

b. SP2 began working in a children’s residential facility on July 15, 2024. At the time of the licensing review on December 2, 2024, the license holder had not submitted a background study request to DHS for SP2.

Because the license holder allowed SP2 to work in a children’s residential facility without submitting a background study request, the license holder is being fined for the background study violation involving SP2.

Statute Violated: Minnesota Statutes 245C.03, subdivision 1 and 245C.04, subdivision 11.

Fine: $200 (one violation at $200 per violation)

Corrective Action Required: You must comply with background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance will be maintained in the future.

Billing and Payment of the Fine

DHS will send you an invoice for the $200 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, you are personally and jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

Your Right to Appeal

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive 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 receive 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

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal Authority for this Licensing Action

· DHS may impose a $200 fine for each background study violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

Questions

If you have any further questions regarding this matter, you may contact Katie Leuer, Supervisor, at 651-431-6259.

Sincerely,

Paula Halverson, 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/