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May 21st, 2024 Elsbeth Ann Holger, Authorized Agent
License Number: 1104909 Report Number: 202401365 CORRECTION ORDER Dear Elsbeth Ann Holger,  On March 25th, 26th, and 27th of 2024 the Department of Human Services (DHS) conducted a licensing review and investigation at your facility, Dignity House, 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, part 2960.0010 through 2960.0120 and shelter care services for children under Minnesota Rules, part 2960.0510 through 2960.0530. As a result of this visit, 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. Physical Plant 1. Violation: 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 residents or in the staff work station. Rule Violated: Minnesota Rule, part 2960.0050, subparts 3, items C and D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service termination policies meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 2. Violation: The facility did not have first aid kits readily available for use by staff Rule Violated: Minnesota Rule, part 2960.0110, subpart 4 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the facility has first aid kits readily available. Policies and Practices 3. Violation: The license holder’s annual evaluation of the program for 2023 did not use the following required performance indicators: i. Accidents; ii. Grievances; iii. Adverse findings, allegations of maltreatment, citations and legal actions against the license holder; iv. Results of resident and family satisfaction surveys; v. The success rate in achieving the intended outcomes of services offered to the resident and the residents family; and vi. Critical incidents. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the evaluation of the program meets all applicable requirements. 4. Violation: One of ten incidents reviewed for requirements governing critical incidents did not meet requirements. On 12/24/2023, law enforcement responded to the program, and a critical incident was not reported to DHS within 10 days. Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure critical incident reporting meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 5. Violation: The license holder did not monitor the implementation of their policies and procedures by program staff. The emergency procedures policy identified that staff should call 911 when a resident runs away. On February 9th, 2024, a resident ran away from the program and law enforcement was not contacted. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure they monitor their implementation of policies and procedures by program staff meets all applicable requirements. Resident Files 6. Violation: One of three resident files reviewed for requirements governing resident information did not contain the following required information: i. The spiritual or religious affiliation of the resident and the resident’s family (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 the provision and documentation of resident information meets all applicable requirements. 7. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements in the following ways: i. The inventory of the resident’s property was not signed (resident files numbered 2 and 3); ii. The resident file did not contain documentation to demonstrate the following: 1. That the facility rules and due process system were communicated verbally and in writing to the resident (resident file numbered 1); 2. That the license holder provided the resident with a written copy of the basic rights within 24 hours (resident file numbered 1); 3. That the license holder informed the resident’s parent, guardian or custodian within a reasonable time after admission that information about the resident’s rights was available (resident files numbered 1, 2, and 3) iii. The license holder did not complete a screen for trauma by completing a trauma-specific screening tool upon the youth’s admission (resident files numbered 1, 2, and 3) Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (c), Minnesota Rules, parts 2960.0080, subpart 4, 2960.0070, subpart 4, and 2960.0050, subpart 3, items A and B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of admission procedures meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 8. Violation: One resident file reviewed for requirements governing vulnerable adults orientation did not meet requirements (resident file numbered 4). There was no documentation to demonstrate the resident was oriented to the internal and external reporting policies, including the telephone number for MAARC and the program abuse prevention plan. Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of vulnerable adults orientation meets all applicable requirements. 9. Violation: Two of three resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways: i. The license holder did not develop a plan to reduce the resident’s risk of maltreatment while in shelter (resident file numbered 3); ii. The resident file did not contain an immediate needs plan (resident file numbered 1); and iii. The immediate needs plan did not specify short-term objectives and methods for meeting the needs identified and did not indicate the license holders responsibilities for meeting the resident’s needs identified by the placing agency (resident file numbered 3). Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, Item A, and 3 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of shelter admissions meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 10. Violation: One of three resident files reviewed for requirements governing daily resident activities did not meet requirements (resident file numbered 2). The resident ran from the program on 02/09/2024 and there was no documentation to demonstrate the license holder immediately notified the referring or placing agency. Rule Violated: Minnesota Rules, part 2960.0080, subpart 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the communication with referring or placing agencies meets all applicable requirements. 11. Violation: Three of three resident files reviewed for requirements governing health care did not meet requirements in the following ways: i. The license holder did not document attempts to contact the child’s parents or guardians to seek permission for the facility to administer medications (resident files numbered 1, 2, and 3); and ii. The license holder did not keep records of the quantity of prescription medications initially received from the pharmacy (resident file numbered 2). Rule Violated: Minnesota Rules, parts 2960.0080, subpart 11, items D and E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. Within 30 days receipt of the order, submit documentation demonstrating staff obtained or attempted to obtain permission to administer medication to a resident. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 12. Violation: Three of three resident files reviewed for requirements governing limitations on length of stay in shelter did not meet requirements in the following ways: i. The license holder did not apply for a variance to retain a resident in shelter beyond 90 days (resident files numbered 3, 5, and 6); and ii. The license holder did not review the need for the resident to remain in the shelter program beyond 30 days (resident file numbered 3). Rule Violated: Minnesota Rules, parts 2960.0530, subparts 1 and 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of limitations on length of stay in shelter meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 13. Violation: Two of two resident files reviewed for requirements governing no eject discharges did not meet requirements (resident files numbered 2 and 4). There was no documentation to demonstrate the license holder conferred with other interested persons to review the issues involved in the decision to eject the resident, and to determine if additional strategies could be developed to permit the resident to continue to receive services from the license holder. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of no eject meets all applicable requirements. Within 30 days receipt of this order, submit documentation of a no-eject discharge that demonstrates compliance. 14. Violation: Two of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident files numbered 1 and 3). The resident file did not contain a signed receipt of the return of the resident’s personal property. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge procedures meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 15. Violation: One resident file reviewed for requirements governing shelter discharge documentation (resident file numbered 3) did not meet requirements in the following ways: i. The license holder did not develop a transition services plan for the resident; and ii. The license holder did not document the name and address of the party the resident was released to following discharge. Rule Violated: Minnesota Rules, parts 2960.0190, subpart 1, item A and 2960.0520, subpart 2, item C Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure shelter discharge documentation meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. Personnel Files 16. Violation: Two of four personnel files reviewed for requirements governing background studies did not meet requirements (personnel files numbered 1 and 3) in the following ways: i. Personnel file 1 began working in the program on 06/21/2023, license number 1104909. A background study was submitted under license number 1074613, but the study was not affiliated with license number 1104909. ii. Personnel file 3 began working in the program on 01/31/2023, license number 1104909. A background study was submitted under license number 1074613, but the study was not affiliated with the license number 1104909. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f) Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of background studies meets all applicable requirements. 17. Violation: Four of four personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: i. Documentation did not demonstrate that the medication assistance training was provided by a post-secondary institution or a registered nurse (personnel files 1, 2, and 3); ii. The staff person was not oriented to the following required topics prior to having unsupervised direct contact with residents: 1. Maltreatment of minors (personnel files numbered 1, 2, and 3); 2. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel file numbered 3); 3. Data practices regulations and issues (personnel files numbered 1, 2, and 3); 4. Concepts of trauma-informed care and how to provide services to each youth according to those concepts (personnel files numbered 1 and 2); 5. Impacts of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences (personnel files numbered 1, 2, and 3); and 6. Human trafficking training approved by the Department of Human Services’ Children and Family Services Administration (personnel files numbered 1, 2, and 3) iii. There was no documentation to demonstrate the staff person was oriented to the following required topics: 1. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 1 and 2); 2. General and special needs, including disability needs of residents and families served (personnel files numbered 1, 2, and 3); and iv. Documentation of orientation did not include the dates and number of hours of orientation completed and the name of the entity that provided the training (personnel files numbered 1, 2, and 3) Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivisions 3, paragraph (h), and 5, paragraph (f), Minnesota Rules, parts 2960.0080, subpart 11, Item D, 2960.0100, subparts 3, item A, and 5 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation meets all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated September 13th, 2021. 18. Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: i. There was no documentation to demonstrate the staff person received annual training in: 1. The program abuse prevention plan, for the calendar year 2023 (personnel files numbered 2 and 4) 2. All internal policies and procedures related to the prevention and reporting of maltreatment, for the calendar year 2023 (personnel file numbered 4) 3. Concepts of trauma informed care and how to provide services according to these concepts (personnel files numbered 3 and 4) 4. Impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma (personnel files numbered 1, 2, 3, and 4) 5. Human trafficking training approved by the Department of Human Services’ Children and Family Services Administration (personnel files numbered 1, 2, 3, and 4) ii. There was no documentation to demonstrate the license holder reviewed the emergency plan with staff at least once every six months, for calendar year 2023 (personnel files numbered 1, 2, 3, and 4). Statute and Rule Violated: Minnesota Statutes, sections 245A.65, subdivision 3, 245A.25, subdivisions 3, paragraph (h), and 5, paragraph (f), Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subpart 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing trainings meet 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 (hannah.horsch@state.mn.us) or mail: Commissioner, Department of Human Services ATTN: Hannah Horsch 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960. · 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 651-431-6259. Sincerely, Katie Leuer, Unit Supervisor Licensing Division Office of Inspector General
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