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April 28, 2023 Carmeann Foster, Authorized Agent Rebound Inc. 710 W Broadway Ave N Minneapolis, MN 55411 License Number: 1100893
CORRECTION ORDER Dear Carmeann Foster: On January 23 through 26, 2023 a licensing review and licensing investigation of Jelani House located at 221 Belvidere St. E., St. Paul, MN 55107, 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, group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and residential shelter services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). As a result of this licensing review and licensing investigation, 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 violations of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Postings 1. Citation: Minnesota Statutes, section 245A.65, subdivisions 1, paragraphs (a) and 2, (d); and Minnesota Rules, part 2960.0050, subpart 3, item D. Violation: The license holder failed to ensure postings met requirements in the following ways: a. A copy of the internal and external reporting policies and procedures for maltreatment were not posted in a prominent location in the facility; b. The license holder maintained a posting of an outdated program abuse prevention plan (PAPP); and c. A copy of the resident’s rights was not posted in the staff work station.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 all postings for vulnerable adult maltreatment meets all applicable requirements. Policies and Practices 2. Citation: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (4) and Minnesota Rules, part 2960.0020, subpart 44; 2960.0030, subpart 2, item B; 2960.0010, subparts 1 and 2; 2960.0040, item D. Violation: The license holder did not notify the Commissioner or obtain approval prior to changing the location of the services provided by Jelani House. The license holder moved residents from the location identified for license number 1100893, Jelani House, to the location of a different licensed facility of the license holder, license number 1076796, Jordan House. Residents slept overnight at Jordan House and attended group services and activities. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure to meet all applicable requirements. During the licensing review, the license holder was ordered to immediately cease the combining of residential programs for overnight sleeping. 3. Citation: Minnesota Statues, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, part 2960.0050, subpart 1, item B Violation: The license holder failed to monitor the implementation of their Cell Phone Protocol policy and to ensure the residents right to privacy was protected. As a result, a critical incident occurred on August 6, 2022 (resident file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their policies meets all applicable requirements. 4. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subpart 11, item D. Violation: The license holder failed to monitor the implementation of their plan for the safe storage and delivery of medicine in the following ways: a. Documentation did not demonstrate that a medically licensed person provided consultation and review of the administration of medications at least monthly for the months of October, November, and December 2022; b. Staff persons responsible for the administration of medications to residents were not provided program specific medication assistance training by the program’s registered nurse; c. Documentation to demonstrate whether medications were packed for home visits or when the resident was away from the facility was inconsistent with the plan; d. Resident documentation indicated that a staff person responsible for administering medications did not have access to the medication locker to administer prescribed medications when the plan indicated they should, resulting in medications not being administered as directed by the prescriber; and e. The process for obtaining and documenting the need for medication refills was not followed as described in the plan. As a result, resident medication was not administered as directed by the prescriber. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their health services policies and procedures meets all applicable requirements. Within 60 days receipt of this order, submit documentation demonstrating the plan for the safe storage and delivery of medicine was reviewed and approved by the program’s current medically licensed professional to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021 5. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A. Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not include the following required performance indicators: a. Accidents; b. The use of restrictive procedures; c. Grievances; d. Results from resident and family satisfaction surveys; and e. Critical incidents Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021 6. Citation: Minnesota Statues, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subparts 6 and 17, item A. Violation: The license holder failed to meet requirements governing critical incidents in the following ways: a. Critical incident reports were not submitted to DHS for six incidents in which a resident absconded and did not return within 24 hours (July 25 and 26, 2022, August 10, 2022(x2), and September 13 and 26, 2022); b. The license holder’s Critical Incident Reporting and Review policy did not define critical incidents according to DHS’s definitions and criteria; and c. The license holder failed to monitor the implementation of their Critical Incident Reporting and Review and Abscond policies in the following ways: 1. Incidents were not documented on the forms or maintained in the resident’s record as described in the Critical Incident Reporting and Review policy; and 2. The notifications to a resident’s referring agent for when a resident ran from the program were not documented in case notes as indicated in the Abscond policy. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their incident reporting policies and procedures meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021 7. Citation: Minnesota Rules, part 2960.0080, 18, item A. Violation: The license holder did not meet requirements governing grievances. The license holder did not demonstrate that a grievance was responded to according to requirements. A DHS Licensor observed through documentation that a grievance, dated August 6, 2022, was filed and the license holder was unable to provide documentation that it was responded to. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the response to grievances meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. Personnel Files 8. Citation: Minnesota Statutes, section 245A.041, subdivision 5. Violation: Two of two personnel files reviewed for requirements governing documentation requirements (personnel files numbered 1 and 3) did not meet requirements. The license holder failed to document the first date the staff person began working in a facility or setting. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0100, subpart 3, item A. Violation: Two of two personnel files reviewed for requirements governing orientation training (personnel files numbered 1 and 3) did not meet requirements in the following ways: a. The staff person was not oriented to general and special needs, including disability needs of families served; and b. The staff person was not oriented within 72 hours of first providing direct contact services to the program abuse prevention plan (PAPP). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Resident Files Resident files reviewed are identified in the following manner: · Shelter: Resident file numbered 2 · Group Residential Setting: Resident file numbered 1 10. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B. Violation: Two of two resident files reviewed for requirements governing resident information did not meet requirements. The resident file did not include the following required information: a. Time of admission (resident files numbered 1 and 2); b. Resident’s written language and tribal affiliation (resident file numbered 2); c. Circumstances leading to admission (resident files numbered 2); d. Description of assets and strengths of the resident (resident file numbered 2); e. Spiritual or religious affiliation of the resident the resident’s family (resident file numbered 2); and f. Attempts to obtain the placing agency’s case plan goals (resident file numbered 1). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident admission information meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 11. Citation: Minnesota Rules, parts 2960.0160, subparts 2, item C. Violation: One of two resident files reviewed for requirements governing admission criteria (resident file numbered 1) did not meet requirements. The file did not contain documentation to demonstrate that the license holder determined they were able to meet the resident’s cultural, emotional, educational, mental health and physical health needs. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission criteria and procedures meet all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 12. Citation: Minnesota Rules, parts 2960.0070, subpart 4 and 2960.0090, subpart 3. Violation: Two of two resident files reviewed for requirements governing the inventory and handling of resident property did not meet requirements in the following ways: a. The resident’s property was not inventoried upon admission (resident files numbered 1); and b. The files did not include a signed receipt demonstrating the license holder returned all of the residents’ personal property (resident files numbered 1 and 2). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the inventory and handling of resident property meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 13. Citation: Minnesota Rules, parts 2960.0520, subparts 2, items A and B, and 3. Violation: One resident file reviewed for requirements governing shelter admissions (resident file numbered 2) did not meet requirements in the following ways: a. A health screening was not arranged for within 24 hours of admission; b. The license holder did not assess the resident’s vulnerability to maltreatment and develop a plan to reduce their risk of maltreatment while in the shelter; and c. An immediate needs plan was not developed. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure shelter admission procedures meet all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 14. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0530, subpart 1. Violation: One resident file reviewed for requirements governing limitations on length of stay in shelter (resident file numbered 3) did not meet requirements. The file did not contain documentation to demonstrate that the license holder applied for a variance to retain a resident in shelter beyond 90 days or followed their policy to transfer an individual from shelter to group residential services. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission screenings meet all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 15. Citation: Minnesota Rules, part 2960.0070, subpart 5, item A. Violation: One resident file reviewed for requirements governing resident screenings (resident file numbered 1) did not meet requirements. The file did not contain documentation to demonstrate that the license holder completed a mental health and substance use disorder screen. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission screenings meet all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 16. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D. Violation: One of two resident files reviewed for requirements governing program services (resident files numbered 1) did not meet requirements. The license holder did not demonstrate that education about chemical health was provided to a resident who has had a problem with inappropriate chemical use, but who does not have sufficient history to refer to treatment. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of program services meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 17. Citation: Minnesota Rules, part 2960.0180, subpart 2, item B.
Violation: One resident file reviewed for requirements governing treatment plans (resident file numbered 1) did not meet requirements. There was no date on the treatment plan to determine that its development began within 10 days of admission. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plans meets all applicable requirements. 18. Citation: Minnesota Rules, part 2960.0080, subpart 11, items D and E. Violation: One of two resident files reviewed for requirements governing health care (resident file numbered 1) did not meet requirements in the following ways: a. The medication administration record for the months of November and December 2022, did not identify whether the resident received the medication on the following dates: 1. November 3,4, 8, 12, 19, 24 and 25, 2022; and 2. December 13, 5, 8-12, 15, 17, 21-25, and 27-31, 2022; b. There was no documentation to demonstrate the license holder contacted the resident’s prescribing medically licensed person to verify information regarding their prescription medication; c. There was no documentation to demonstrate the license holder followed the prescribing physician’s directions for monitoring medications used by the resident; and d. There was no documentation to demonstrate the license holder recorded the initial quantity of medication received by the pharmacy. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the delivery and documentation of medicine meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 19. Citation: Minnesota Rules, part 2960.0090, subpart 2. Violation: One resident file reviewed for requirements governing a no-eject discharge (resident file numbered 2) did not meet requirements. The file did not contain documentation to demonstrate the following: a. The license holder conferred with other interested persons to review the issues involved in the decision to discharge a resident prior to reaching their case plan goals; b. If any additional strategies to resolve the issues leading to discharge could have been developed to allow the resident opportunity to continue receiving services; and c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of no-eject discharges meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. 20. Citation: Minnesota Rules, parts 2960.0190, subparts 1, items A and C, and 2, items A and B; and 2960.0520, subpart 2, item C. Violation: One resident file reviewed for requirements governing discharge procedures, documentation, and the transition services plan (resident file numbered 1) did not meet requirements in the following ways: a. There was no documentation to demonstrate the resident’s projected discharge date was provided to all applicable parties; b. The transition services plan did not include the following: 1. The date it was completed; 2. Resources available in the community to address the resident’s continued needs after discharge from the program; 3. Consideration of the environment the resident will return to and recommendations of how they might deal with potential issues and challenges within that environment; 4. Documentation to demonstrate the plan was developed with input from the resident, the resident’s family, and if appropriate, the providing school district, and anyone who will provide support services upon discharge from the program; and 5. Documentation to demonstrate that a copy of the plan was given to the resident, the school, or if applicable, to the residential treatment facility the resident was placed in upon/after discharge; and c. The discharge documentation did not identify the extent to which the resident’s stay in the program met the goals and objectives of their treatment plan and who provided those services. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure discharge procedures and documentation meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021. If you fail to correct the violations 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 a corrective action ordered must be sent to DHS Licensing at: 1. By secure email to: tina.christensen@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Tina Christensen 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 me as soon as possible. Tina Christensen, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6610
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