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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
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