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July 31, 2025 Sheri Reimers, Authorized Agent Ain Dah Yung Center
License Number: 800051 (CRF) CORRECTION ORDER Dear Sheri Reimers:  On May 13 and 14, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Ain Dah Yung Center, located at . This review 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; and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. 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. Policies, Procedures and Practices 1. Violation: The license holder's policy on reporting maltreatment of minors did not meet requirements. The policy did not reference chapter 260E, it referenced a repealed statute that is no longer applicable. Statute Violated: Minnesota Statute, section 245A.66 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the Maltreatment of Minors reporting policy meets requirements. 2. Violation: The license holder’s policy on emergency plans did not meet requirements. The plan did not include a response to a natural disaster. Rule Violated: Minnesota Rules, part 2960.0080, subpart 14. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure emergency plans meet requirements. 3. Violation: The license holder’s plan for the transfer of clients and records did not meet requirements. An annual review of the plan was not completed in 2024. Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the ongoing review of the plan for transfer meets requirements. 4. Violation: The license holder’s program evaluation did not meet requirements. There was no documentation to demonstrate an annual evaluation of the program’s strengths and weaknesses was completed for calendar years 2023 and 2024. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure outcome measures meet requirements. Within 30 days receipt of this order, submit documentation demonstrating how an annual evaluation will be completed. Personnel Files 5. Violation: Two of two personnel files reviewed for orientation training did not meet requirements (personnel files numbered 1 and 5). There was no documentation to demonstrate orientation to the following required topics was provided prior to direct contact services: a. Emergency procedures; b. Maltreatment of Minors reporting requirements; c. Cultural diversity and gender sensitivity, culturally specific services and information about discrimination and racial bias issues; d. General and special needs, including disability needs of residents and families served; e. Operational policies and procedures of the license holder; f. Data practices regulations and issues; and g. There was no documentation to demonstrate the staff person received training on administering admission screenings. Rule Violated: Minnesota Rules, parts 2960.0100, subpart 3, item A; and 2960.0070, subpart 5. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel files numbered 1 and 5 to demonstrate compliance. 6. Violation: Three of three personnel files reviewed for ongoing training did not meet requirements (personnel files numbered 2, 3 and 4). There was no documentation to demonstrate the staff person received ongoing training for calendar years 2023 and 2024 on the following required topics: a. Training that is modified annually to meet the current needs of individual staff persons and is directly related to serving the programs target population and achieving program outcomes; b. Training on program policies and procedures necessary to maintain compliance with licensing requirements; c. Training that helps staff meet the needs of residents, and includes skill development; d. Maltreatment of minors reporting requirements; e. Review of the emergency plans every six months; and f. The date, name of trainer, topic of training and length of training. Statute and Rule Violated: Minnesota Statute, sections 245A.04, subdivision 14, paragraph (b); 245A.66, subdivision 4; and Minnesota Rules, parts 2960.0100, subparts 3, item B, and 5; and 2960.0080, subpart 14. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel files numbered 2, 3 and 4 to demonstrate compliance. Resident Files 7. Violation: One of three resident files reviewed for resident admission documentation did not meet requirements. The resident file did not include the placing agency’s case plan goals for the resident, and there was no documentation demonstrating the license holder attempted to obtain a copy of the plan (resident file numbered 1). Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that resident admission information meets all applicable requirements. 8. Violation: Two of three resident files reviewed for admission procedures did not meet requirements in the following ways: a. An assessment of the resident’s vulnerability to maltreatment, and a plan to reduce the risk of maltreatment while in shelter, was not completed (resident file numbered 2); b. The license holder did not inventory the resident’s personal property upon admission (resident file numbered 2); and c. The license holder provided a copy of resident’s basic rights that included inaccurate information. The copy of the rights included information on the license holder’s grievance procedure, which stated that the person could contact outside government entities if the grievance was not resolved (resident file numbered 1). Rule Violated: Minnesota Rules, parts 2960.0520, subpart 2, item A; and 2960.0050, subpart 3, item A and 2960.0070, subpart 4. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. 9. Violation: Three of four files reviewed for requirements governing health care did not meet requirements in the following ways: a. The license holder did not ensure the resident’s right to adequate medical care was protected (resident file numbered 1). Admission documentation dated July 29, 2024, identified the need for dental and eye examinations. A case note dated October 21, 2024, indicated the resident requested appointments for these examinations. A case note identified that the resident complained of dental pain and attended an emergency dental appointment on February 18, 2025 (resident file numbered 1); b. Documentation did not identify the initial quantity of medication received from the pharmacy (resident files numbered 1, 2 and 3); and c. The medication administration record did not document the amount of medication given, the dosage, and time when the medication was taken (resident file numbered 1). Rule Violated: Minnesota Rules, parts 2960.0050, subpart 1, item F, 2960.0080, subpart 11, item E. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care meets all applicable requirements. 10. Violation: Two of two resident files (resident files numbered 1and 4) reviewed for no eject did not meet requirements in the following ways: a. The license holder did not document conferring with interested persons to review issues involved in the decision to discharge; b. The license holder did not document whether they, together with other interested persons, attempted to develop additional strategies to resolve the issues leading to discharge within a five-day period; c. The license holder did not document if the discharge was warranted, the reasons for it and the alternatives considered or attempted. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2. Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that no eject meets all applicable requirements. Within 30 days receipt of this order, submit documentation of a no-eject discharge to demonstrate compliance. 11. Violation: One resident file (resident file numbered 1) reviewed did not meet requirements governing the license holder’s compliance with an approved variance extending the length of stay in a shelter. There was no documentation to demonstrate the license holder complied with a condition of the variance approval dated 10/30/2024 to provide at least 10 hours of services per week. Rule Violated: Minnesota Statute, section 245A.04, subdivision 9. Corrective Action Required: Immediately and on an ongoing basis, the license holder must follow all terms of approved variance requests. 12. Violation: Two of two resident files reviewed for discharge procedures did not meet requirements. The license holder did not document return of the resident’s belongings with a signed receipt (resident files numbered 1 and 4). Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meets all applicable requirements. 13. Violation: Two of two resident files reviewed for transition services plan did not meet requirements in the following ways: a. The license holder did not document input from the resident’s family members, school or support services (resident file numbered 2); b. The license holder did not document providing a copy of the transition plan to family members, school or support services (resident files numbered 1 and 2). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plan meets all applicable requirements. Written Response Required If you fail to correct the violation(s) 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 the corrective action ordered must be sent to your licensor by email at Laura.Huff1@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Laura Huff 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: 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 - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. 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 651-431-4234 or at Laura.Huff1@state.mn.us Sincerely, Laura Huff, Licensor Licensing Division Office of Inspector General
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