|
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
|
