|
July 28, 2023 Jacob Margarit, Authorized Agent 2485 Como Ave. Saint Paul, MN 55108 License Number: 800188 (CRF) CORRECTION ORDER Dear Jacob Margarit,  On June 6 and 7, 2023, the Department of Human Services (DHS) conducted a licensing review at your facility, LSS Bethany Crisis Shelter, located at . 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. PERSONNEL FILES 1. Violation: One of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 2). There was no documentation of orientation to operational policies and procedures. Rule Violated: Minnesota Statute 245A.04, subdivision 1 and Minnesota Rules, part 2960.0100, subpart 3, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of orientation meets all applicable requirements. 2. Violation: One of two personnel files reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 3). A review of the emergency plan was not completed at least once every six months in 2022. Rule Violated: Minnesota Rules, part 2960.0080, subpart 13. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of ongoing training meets all applicable requirements. RESIDENT FILES 3. Violation: Three of three resident files reviewed for requirements governing resident admission documentation did not meet requirements. The resident file did not contain the following: a. The language the resident writes (resident files numbered 1 through 3); b. A description of the resident’s assets and strengths (resident files numbered 2 and 3); and c. The spiritual or religious affiliation of the resident’s family (resident files numbered 1 through 3). 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 completion of resident admission documentation meets all applicable requirements. 4. Violation: One of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident file numbered 2). There was no documentation to demonstrate that the resident was given a written copy of the resident’s basic rights information within 24 hours. Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item A. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission procedures meet all applicable requirements. 5. Violation: One resident files reviewed for requirements governing shelter discharge documentation did not meet requirements (resident file numbered 2). The resident file did not contain a transition services plan, and the resident remained in the shelter for more than 10 days. Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item C and part 2960.0190, subpart 1, item A. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure shelter discharge documentation meets all applicable requirements. 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
|
