|
February 9, 2023 Holly Henning, Authorized Agent Ain Dah Yung (Our Home) Center
License Number 800051 (CRF) License Number 810437 (CRF) AMENDED CORRECTION ORDER Dear Holly Henning:  On February 14 through 16, 2022, a licensing review of Ain Dah Yung (Our Home) Center, located at  , and Beverly A. Benjamin Youth Lodge, located at 1212 Raymond Avenue, Saint Paul, MN 55108, 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; transitional services under Minnesota Rules, part 2960.0500; and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. As a result of the licensing review a Correction Order was issued. On February 9, 2023, DHS licensing rescinded the repeat violation from citation numbered 5 from the Correction Order dated May 4, 2022. The amended Correction Order supersedes the Correction Order issued on May 4, 2022, which must be destroyed. Physical Plant, Policies, and Practices 1. Citation: Minnesota Rules, part 2960.0110, subpart 4. Violation: The program did not have a first aid kit readily available for use by the residents. The first aid kit was kept in a locked staff office, inaccessible to residents (YL). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure physical plant requirements meet all applicable requirements. The violation was corrected during the licensing review, no further corrective action is required. 2. Citation: Minnesota Rules, part 2960.0050, subparts 1 and 3, items A, C, and D. Violation: The license holder’s policy and practice for Minnesota Rules 2960 basic rights did not meet requirements in the following ways (YL): a. The license holder’s policy did not include Minnesota Rules 2960.0050, subpart 1 basic rights. Therefore, residents were not given a written copy of the resident’s basic rights information within 24 hours of admission; b. A copy of the resident’s rights were not posted in an area of the facility where it can be readily seen by staff and the resident; and c. A copy of the resident’s rights was not posted in the staff work station. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident’s basic rights meet all applicable requirements. Within 30 days of receipt of this order, submit a resident’s basic rights policy that meets all applicable requirements (YL). Submit documentation resident’s basic rights was posted and meets all applicable requirements (YL). 3. Citation: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Violation: A controlling individual did not annually review and sign the plan for transfer of clients and record upon closure for calendar years 2019, 2020, and 2021, (ALL). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure a controlling individual annually reviews the plan for transfer of clients and records upon closure. Within 30 days of receipt of this order, submit documentation a controlling individual reviewed the plan for transfer of clients and records upon closure (ALL). 4. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: The license holder’s practice with the Program Abuse Prevention Plan (PAPP) did not meet requirements in the following ways (YL): a. The license holder had multiple versions of the PAPP posted in a prominent location in the program. It was unclear which version was correct; and b. The governing body or delegated representative did not review the PAPP annually for calendar years 2020 and 2021. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the practice of the PAPP meets all applicable requirements. The license holder posted the correct PAPP during the licensing review. Within 30 days receipt of this order, submit documentation of the governing board or delegated representative reviewed the PAPP for calendar year, 2022. 5. Citation: Minnesota Rules, parts 2960.0060, subpart 3, items A and B; and 2960.0500, subparts 7, and 8. Violation: The licenses holder’s evaluation of outcome measures did not meet requirements in the following ways: a. The license holder did not annually evaluate the strengths and weaknesses of the program for calendar years 2020 and 2021 (ADY); b. The license holder did not measure, at least quarterly, the license holder’s success in achievement of the program outcomes identified according to Minnesota Rules 2960, subpart 6. Quarterly documentation was not provided for 2020 and 2021 (YL); and c. The license holder did not monitor and annually evaluate the effectiveness of the facility’s program and resident satisfaction with individual program services (YL). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the outcome measures meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of an annual review for Ain Dah Yung Center and quarterly review of Youth Lodge outcome measures that meets all applicable requirements. 6. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A. Violation: The license holder did not submit a critical incident report for incidents dated January 22, 2021; January 30, 2021; and April 14, 2021 when emergency responders were called (ADY). Corrective Action Ordered: immediately and on an ongoing basis, the license holder must ensure the practice for critical incident reports meets all applicable requirements. Personnel Personnel files reviewed are identified in the following manner: · Personnel files numbered 4 and5 (ADY) · Personnel files numbered 6,7,9,10, and 12 (YL) · Personnel files numbered 1, 2, 3, 8, 11, 13, and 14 (ALL) 7. Citation: Minnesota Statutes, section 245C.07, paragraph (f). Violation: Eight of fourteen personnel files reviewed for requirements governing background studies did not meet requirements. The license holder has multiple programs but failed to affiliate a person on all active rosters: a. Staff person (personnel file numbered 7) began a position allowing direct contact with persons served by the program on June 29, 2018. A BGS was submitted under licensed number 800051; however, SP7 was working under license number 810437. The license holder failed to affiliate SP7 to the correct roster. b. Staff person (personnel file numbered 8) began a position allowing direct contact with persons served by the program on April 12, 2019. A BGS was submitted under licensed number 800051; however, SP8 was working under license number 810437. The license holder failed to affiliate SP8 to the correct roster. c. Staff person (personnel file numbered 9) began a position allowing direct contact with persons served by the program on September 20, 2021. A BGS was submitted under licensed number 800051; however, SP9 was working under license number 810437. The license holder failed to affiliate SP9 to the correct roster. d. Staff person (personnel file numbered 10) began a position allowing direct contact with persons served by the program on February 27, 2021. A BGS was submitted under licensed number 800051; however, SP10 was working under license number 810437. The license holder failed to affiliate SP10 to the correct roster. e. Staff person (personnel file numbered 11) began a position allowing direct contact with persons served by the program on June 3, 2010. A BGS was submitted under licensed number 800051; however, SP11 was working under license number 810437. The license holder failed to affiliate SP11 to the correct roster. f. Staff person (personnel file numbered 12) began a position allowing direct contact with persons served by the program on September 5, 2017. A BGS was submitted under licensed number 800051; however, SP12 was working under license number 810437. The license holder failed to affiliate SP12 to the correct roster. g. Staff person (personnel file numbered 13) began a position allowing direct contact with persons served by the program on March 16, 2020. A BGS was submitted under licensed number 800051; however, SP13 was working under license number 810437. The license holder failed to affiliate SP13 to the correct roster. h. Staff person (personnel file numbered 14) began a position allowing direct contact with persons served by the program on January 30, 2020. A BGS was submitted under licensed number 800051, however, SP14 was working under license number 810437. The license holder failed to affiliate SP14 to the correct roster. Corrective Action Ordered: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, section 245C. Within 10 days of receipt of this order, submit written documentation to your licensor detailing how compliance has been achieved and how compliance will be maintained in the future. 8. Citation: Minnesota Rules, part 2960.0100, subpart 6, item B. Violation: One of eight personnel files reviewed for requirements governing staff qualifications (personnel file numbered 8) did not meet requirements. The file did not contain documentation the staff was trained in gender-based needs and issues. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure staff qualifications meets all applicable requirements. 9. Citation: Minnesota Rules, part 2960.0150, subpart 2. Violation: Two of two personnel files reviewed for requirements governing professional licensure (personnel files numbered 2 and 3) did not meet requirements. The file did not contain documentation of a current professional license. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all requirements governing professional licensure meet all applicable requirements. The violation was corrected during the licensing review, no further corrective action is required. 10. Citation: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c) and Minnesota Rules, part 2960.0100, subpart 3, item A Violation: Three of five personnel files reviewed for requirements governing orientation training did not meet requirements. The personnel file did not contain documentation of orientation to the following subjects before unsupervised direct contact with residents: a. Emergency procedures (personnel file numbered 8); b. General and special needs, including disability needs, of residents and families served (personnel files numbered 1, 4, and 8); and c. Operational policies and procedures of the license holder, include the program’s drug and alcohol policy (personnel file numbered 8). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation staff (personnel file numbered 8) was trained on emergency procedures and the operational policies and procedures of the license holder, including the program’s drug and alcohol policy. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 3; and Minnesota Rules, parts 2960.0100, subpart 3, item B; and 2960.0080, subpart 14. Violation: Six of six personnel files reviewed for requirements governing ongoing training did not meet requirements. The personnel file did not contain the following documentation: a. Staff received ongoing training in calendar year 2021, that helped staff meet the needs of the residents and included skill development (personnel files numbered 2 and 3); b. Staff was trained annually on vulnerable adults maltreatment reporting requirements and definitions in calendar year 2021 (personnel file numbered 7); c. Staff was trained annually on the program abuse prevention plan annually in calendar year 2021 (personnel file numbered 6); and d. The emergency plan was reviewed at least once every six months in calendar year 2021 (personnel files numbered 1 through 3 and 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements. 12. Citation: Minnesota Rules, part 2960.0100, subpart 5. Violation: Seven of seven personnel files reviewed for requirements governing the documentation of training did not meet requirements in the following ways: a. The files did not include complete documentation that showed the date, number of hours of orientation and the staff person in each topic area that provided the orientation for years 2020 and 2021(personnel files numbered 1 through 3, and 5 through 7); and b. The number of hours of in-service training (personnel file numbered 8). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of training includes all required components and meets all applicable requirements. 13. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h). Violation: Six of six personnel files reviewed for requirements governing trauma informed care training (personnel files numbered 1 through 5, and 8) did not meet requirements. The personnel file did not contain documentation the license holder trained each staff on the concepts of trauma-informed care and how to provide services to each youth according to those concepts when the program became certified as a residential setting 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. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma informed care training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation all staff have been trained on the license holder’s trauma informed care policies. Resident Files Resident files reviewed are identified in the following manner: · Resident files numbered 1 through 4 (ADY) · Resident files numbered 5 through 7 (YL) 14. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B. Violation: Six of six resident files reviewed for requirements governing resident admission documentation did not meet requirements. Documentation did not include the following: a. Assaultive behavior concerns (resident files numbered 1 through 3); b. Time of admission (resident file numbered 5); c. Languages spoken and written (resident files numbered 5 and 6); d. Spiritual or religious affiliation (resident files numbered 5 through 7); and e. The placing agency’s case plan goals for the resident (resident files numbered 1 and 3). 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 September 24, 2019. 15. Citation: Minnesota Rules, part 2960.0050, subpart 3, item B. Violation: Two of three resident files reviewed for requirements governing basic rights information (resident files numbered 1 and 3) did not meet requirements. The license holder did not 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 is available. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that basic rights information meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for two resident files (ADY) for basic rights information that demonstrates compliance. 16. Citation: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b); and 626.557, subdivision 14, paragraph (b). Violation: Two of two resident files reviewed for requirements governing the individual abuse prevention plan (IAPP) did not meet requirements in the following ways: a. The file did not contain an IAPP (resident file numbered 7); and b. The IAPP did not include the following after the resident’s needs changed after intake (resident file numbered 5): 1. An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults, and to self-abuse; and 2. Specific measures that will be taken to minimize the risk of abuse to the person when the individual assessment indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the IAPP meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of an IAPP for two residents (YL) that demonstrates compliance. 17. Citation: Minnesota Rules, part 2960.0520, subpart 2, item A. Violation: Three of three resident files reviewed for requirements governing shelter admissions (resident files numbered 1 through 3) did not meet requirements. The file did not contain documentation the license holder assessed the residents vulnerability to maltreatment and developed a plan reduce the resident’s risk of maltreatment while in the shelter. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that shelter admissions meet all applicable requirements. Within 30 days of receipt of this order, submit documentation of risk assessments, including a plan to reduce the risk of maltreatment if applicable for two residents (ADY) that demonstrate compliance with requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 24, 2019. 18. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D. Violation: One resident file was reviewed for requirements governing education services (resident file numbered 1) and did not meet requirements. The file did not contain documentation the license holder provided education about chemical health to a resident who has a history of inappropriate chemical use but does not have a sufficient chemical use history to refer to treatment. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that education services meet all applicable requirements. 19. Citation: Minnesota Rules, part 2960.0080, subpart 11, item E. Violation: Three of three resident files reviewed for requirements governing health and hygiene services (resident files numbered 1 through 3) did not meet requirements. The license holder did not consistently document the quantity of medications received from the pharmacy. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that health and hygiene services meet all applicable requirements. 20. Citation: Minnesota Rules, part 2960.0090, subpart 2. Violation: Four of four resident files reviewed for requirements governing no eject 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 (resident files numbered 1, 3, 6, and 7); 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 (resident files numbered 1, 6, and 7); and c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted (resident files numbered 1, 3, 6, and 7). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the no eject process meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for one resident (all) that demonstrates compliance. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 24, 2019. 21. Citation: Minnesota Rules, parts 2960.0190, subpart 1, item A; and part 2960.0520, subpart 2, item C. Violation: Two of two resident files reviewed for requirements governing transition service plans (resident files numbered 2 and 4) did not meet requirements. The file did not contain a transition service plan. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the transition service plan meets all applicable requirements. Within 30 days of receipt of this order, submit a transition service plan for two residents (ADY) that demonstrates compliance. 22. 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, 2, and 4) did not meet requirements. The file did not contain documentation the license holder screened for trauma by completing a trauma-specific screening tool with the youth upon the youth’s admission or obtained 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. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma informed care meet all applicable requirements. Within 30 days of receipt of this order, submit documentation for two residents for trauma informed care that demonstrates compliance (All). 23. Citation: Minnesota Statutes, section 245A.25, subdivision 5, item D. Violation: One of three resident files reviewed for requirements governing trafficking prevention (resident file numbered 1) did not meet requirements. The file did not contain documentation the license holder provided trafficking prevention education curriculum to the youth. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trafficking prevention meets all applicable requirements. If you have any questions regarding this Amended Correction Order, please contact Maddy Gilbertson, Senior Licensor at 651-448-3583, as soon as possible.  Licensing Division Office of Inspector General PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer http://www.dhs.state.mn.us/licensing
|
