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June 22, 2023 Jacob Thomas Margarit, Authorized Agent LSS Life Haven 325 Jenks Ave St. Paul, MN 55130 License Number 1020196 (CRF) CORRECTION ORDER Dear Jacob: On April 11, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 325 Jenks Ave, St. Paul 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, and transitional services under Minnesota Rules, part 2960.0500. As a result, DHS is issuing this order which requires you to take the correction 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. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subpart 14 and 2960.0100, subpart 3, item A. Violation: Three of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel files numbered 1 through 3). There was no documentation of the following: a. Training in general and special needs, including disability needs, of resident and families served; Corrective Action Ordered: Immediately and on an ongoing basis, the license must ensure training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons numbered 1 through 3 have received training as identified above. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: a. There was no documentation that staff received annual training in vulnerable adult maltreatment reporting requirements (personnel files numbered 2 and 3); and Corrective Action Ordered: Immediately and on an ongoing basis, the license must ensure training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons numbered 1 through 3 have received training as identified above. RESIDENT FILES 3. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B. Violation: Three of three resident files reviewed for requirements governing resident admission documentation did not meet requirements. The file did not contain the following: a. The date and time of admission (resident files numbered 3); b. The language the resident speaks and writes (resident files numbered 1 through 3); c. A description of presenting safety concerns including assaultive behavior and victimization concerns (resident files numbered 2 and 3); and d. The spiritual or religious affiliation of the resident and the resident’s family. Corrective 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 a Correction Order dated December 30, 2020. 4. Citation: Minnesota Rules, part 2960.0050, subpart 3, item B. Violation: Two of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 2 and 3). The license holder failed to notify the resident’s parent, guardian, or custodian, within a reasonable time after admission to the facility that information on the resident’s basic rights was available. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident rights meets all applicable requirements. 5. Citation: Minnesota Statutes, sections 245A.65, subdivisions 1 and 2. Violation: One resident file reviewed for requirements governing vulnerable adults did not meet requirements. The resident file did not contain documentation of the following: a. Orientation to the internal and external vulnerable adult maltreatment reporting policies, (resident file numbered 1); Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure maltreatment of vulnerable adults meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of a corrective action ordered must be sent to DHS Licensing at: 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Gilbertson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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 Questions If you have any further questions regarding this matter, you may contact Maddy Gilbertson, Senior Licensor, at 651-431-4585. Sincerely,
Maddy Gilbertson, Senior Licensor
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