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March 17, 2025 Melissa Bruns, Authorized Agent Hope Harbor 219 N. High St. Marshall, MN 56258 License Number: 1036261 (CRF) CORRECTION ORDER Dear Melissa Bruns: On January 27 through 29, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Hope Harbor, located at 219 N. High St., Marshall, MN, 56258. 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 group residential settings under Minnesota Rules, parts 2960.0130 through 2960.0220. 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 and Procedures and Practices 1. Violation: The license holder’s written program descriptions, and policies and procedures that implement the program described, did not meet requirements. The descriptions suggest that participating in and attending spiritual and religious components and activities of the program is required, and that lack thereof, is considered as a basis for privileges in the facility. Residents and staff reported this to be their understanding as well. Additionally, the offering of alternative programming components and activities described by the license holder during the onsite licensing review were not included in the program descriptions or policies and procedures. Rule Violated: Minnesota Rules, parts 2960.0080, subpart 8, item A; 2960.0160, subpart 4, items A and B; and 2960.0180, subpart 2, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the written program descriptions and policies and procedures that implement the program described meet all applicable requirements. Within 30 days of receipt of this order, submit revised program descriptions and applicable policies and procedures that demonstrate compliance. 2. Violation: The license holder’s plan for transfer of clients and records upon closure did not meet requirements for the transfer of closed case records in the following ways: a. The plan did not include either a signed agreement or other documentation indicating that a county or similarly licensed provider has agreed to accept and maintain the program’s closed case records if the organization closes; and b. The plan included a statement that the license holder would maintain client records for up to one year, however, Minnesota Statutes, section 245A.041, subdivision 3, requires a license holder to maintain all records related to the licensed program, including client records, for five years from the date of closure. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the plan for transfer of clients and records upon closure meets all applicable requirements. Within 30 days of receipt of this order, submit a revised plan for transfer of clients and records upon closure that demonstrates compliance. 3. Violation: The license holder’s grievance procedure did not meet requirements in the following ways: a. It did not indicate that upon receiving a compliant, the license holder would give the person who wants to make a grievance, the necessary forms to file the grievance; and b. It did not include that a person filing a grievance would receive a response within five days from the initial date of the compliant. Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the grievance procedure meets all applicable requirements. Within 30 days of receipt of this order, submit a revised grievance procedure that demonstrates compliance. 4. Violation: The license holder’s annual training plan did not meet requirements. The plan did not include how the license holder determines the amount of training that is needed for a volunteer based upon the position description, tasks to be performed, and the performance indicators of the position, including the amount of in-service training per year for a volunteer consistent with their duties and directly related to the needs of children in their care. Rule Violated: Minnesota Rules, part 2960.0150, subpart 4, items A and B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual training plan meets all applicable requirements. 5. Violation: An internal review for a report of alleged or suspected maltreatment of a minor, dated October 2, 2023, was not completed within 30 calendar days from when the report was made. Statute Violated: Minnesota Statutes, section 245A.66. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the internal review for an alleged report of maltreatment of a minor meets all applicable requirements. 6. Violation: The license holder did not provide for the safe storage and delivery of medications. The license holder allowed for over-the-counter medications to be administered to residents without a written order by a prescribing physician. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the administration of medications meet all applicable requirements. Within 30 days of receipt of this order, submit a revised plan for the safe storage and delivery of medicine and applicable template(s)/form(s) for obtaining written medication orders and for recording the administration of medications that demonstrates compliance. Repeat Violation: In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement. Personnel Files 7. Violation: Two of five personnel files reviewed for requirements governing the provision of background studies did not meet requirements in the following ways: a. As a result of a licensing review, a DHS Licensor determined that the license holder failed to submit a background study before an adult, regardless of whether the individual will have direct contact with persons served by the children’s residential facility, began working in the facility or setting and allowed for the staff person to have access to people served by the program before a BGS notice was issued: i. SP1 began working in a children’s residential facility on August 19, 2024, however, the license holder did not submit a BGS request to DHS for SP1 until August 24, 2024, and a BGS notice was not issued until August 31, 2024. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), except for BGS violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a BGS violation before the commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a BGS violation may not avoid a fine for a subsequent BGS violation unless at least 365 days have passed since the license holder self-corrected the earlier BGS violations. Because the license holder self-corrected the background study violation involving SP1 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP1; and b. The license holder did not document the first date that a person who is a background study subject begins working in the license holder’s facility or setting (personnel files numbered 1 and 3). Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 11, 245C.13, subdivision 2, and 245A.041, subdivision 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of background studies meet all applicable requirements. 8. Violation: One of two personnel files reviewed governing annual training (personnel file numbered 4) did not meet requirements. Training was not completed annually, for calendar years 2023 and 2024, to the following: a. Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; b. All internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults receiving services; and c. The license holder’s program abuse prevention plan (PAPP). Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of annual training meets all applicable requirements. Resident Files 9. Violation: One of three resident files reviewed for requirements governing the administration of medication (resident file numbered 1) did not meet requirements in the following ways: a. The license holder did not document and follow the prescribing physician’s directions for monitoring medications used by the resident in the following ways: i. A medication change was noted on the medication administration record (MAR) in the month of August 2024, however, there was not an order for the medication change in the resident’s file; ii. The directions for administering a medication on the resident’s MAR did not match the physicians order, dated July 12, 2024, for the time of the day the medication was to be administered; and b. The records for a resident who receives prescription drugs at the facility did not meet requirements in the following ways: i. In the month of June 2024, medications were documented to have been given on a date that the resident had not been in admittance to the program and there was no documentation to demonstrate medications were administered on a day the resident was identified as present in the facility; and ii. In the month of August 2024, a medication appeared to have been documented as given, however, there was a line drawn through with no notes indicating if the medication was administered or not. Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D and E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of medication administration meets all applicable requirements. Repeat Violation: In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement. 10. Violation: One resident file reviewed governing discharge requirements (resident file numbered 3) did not meet requirements. The license holder did not document the inventory of the property returned to the resident at discharge to demonstrate any discrepancies between the admission inventory and the discharge inventory. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the inventory of a resident’s belongings at discharge 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 tina.christensen@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Tina Christensen 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 651-431-6610 or at tina.christensen@state.mn.us . Sincerely, Tina Christensen, Lead Licensor Licensing Division Office of Inspector General
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