Lakeside Academy

Violation cited by DHS

The license holder did not ensure that housekeeping and maintenance services were operated on a consistent and healthy basis to ensure the facility was kept in good repair. DHS licensors observed the following: a. The main hall and bedroom walls and vents had handprints, graffiti, holes, dents, and food and other substances dried to them; b. Windowsills contained built up dirt and leaves; c. Two shower stalls were dirty; d. Sprinkler heads in bedrooms were covered in spitballs; e. A broken drawer in a bedroom dresser had sharp screws exposed (corrected on site); and f. Items were hanging from exposed pipes in bedrooms.

Violation cited by DHS

The license holder did not meet the needs of residents and ensure resident rights were protected in the following ways: a. The license holder did not ensure the right to proactive adult guidance, support, and supervision was protected in a manner that would meet the needs of the residents. During a licensing investigation, DHS determined through review of resident files and program documentation, and resident and staff interviews, that a significant incident had occurred involving a physical altercation between residents that had lasted for more than ten minutes before a staff person intervened. On March 2, 2025, after a heightened verbal and physical conflict amongst four residents had occurred, two of those residents lured and pushed a third resident into a recreation room where the fourth resident was awaiting, and at which time the third and fourth resident engaged in a physical altercation that resulted in injuries to both residents; and b. The license holder did not ensure the rights to reasonable communication and visitation with family, and unrestricted visitation with parents were protected, and that the policies were compatible with the needs of the residents. Review of policies and procedures, and interviews with residents and staff, during the on-site licensing review, determined the license holder’s Communication and Visitation policies, LASH 200 & 220, included the following: i. Restrictions on the visiting rights of the parents of a resident beyond the ...

Violation cited by DHS

The license holder did not develop and monitor the implementation of program policies and procedures as necessary to maintain compliance with licensing requirements under Minnesota Statutes and Rules, as accordingly for the following areas: a. The license holder provides both children’s residential SUD services under MN Rules 2960 and is licensed to provide outpatient SUD services at the same location. The license holder’s indicated practice is to classify youth under the children’s residential facility license as either those receiving children’s residential SUD services or straight group residential who receive outpatient treatment services under 245G. The following policies and procedures did not identify this practice: i. Statement of intended use; ii. Admission policy; and iii. Program Description; b. The Maltreatment of Minors reporting policy did not reference current Minnesota Statutes, section 260E; c. The written Grievance Procedure did not meet requirements. The license holder maintains two separate Grievance Procedures that are contradictory of each other; one within the policy and procedure manual, and the other within the student handbook; d. The Plan for the Safe Storage and Delivery of medicine was not updated when the license’s holder practice to use a pharmacy to verify a newly admitted resident’s prescribed medications received approval; e. The HIV Minimum Standards policy was not consistent with the current HIV Minimum Standards approved by the ...

Violation cited by DHS

The license holder’s admission policy did not include the following: a. The staff who are authorized to discharge residents; and b. A protocol for addressing the needs of individuals in need of emergency medical care not provided by the program and individuals who pose a substantial likelihood of harm to themselves or others, if the behavior is beyond the behavior management capabilities of the program and staff.

Violation cited by DHS

The license holder’s Plan for Transfer Upon Closure did not meet requirements in the following ways: a. The information on how clients would access their records was not identified; b. The arrangements the program would make to transfer current clients and their records to another provider or county agency for the continuation of services were not identified; and c. Annual reviews, including a signature, by a controlling individual of the program, were not completed for calendar years 2023 and 2024.

Violation cited by DHS

The license holder’s Drug and Alcohol policy did not meet requirements. The policy identified specific types of chemicals, which are contradictory to statute, and it did not identify: a. Subcontractors and volunteers; and b. A chemical that impairs the individual’s ability to provide services or care.

Violation cited by DHS

The license holder’s Program Abuse Prevention Plan was not reviewed, at least annually, by the license holder’s governing body for calendar years 2023 and 2024.

Violation cited by DHS

The license holder’s written schedule of daily activities did not describe the residents’ activities for each day of the week. The schedule did not include weekends.

Violation cited by DHS

The license holder did not develop a plan that offers appropriate recreation for residents.

Violation cited by DHS

The license holder did not document the provision of culturally appropriate care to each resident including the following: a. Opportunities to associate with culturally and racially similar adults, peers, and role models; b. Opportunities to participate in positive experiences related to the residents’ cultural and racial group; and c. Efforts to contact a cultural or racial community group related to the resident’s cultural or racial minority background and seek information about how to provide opportunities for the resident to associate with adult and peer role models with similar backgrounds on a regular basis.

Violation cited by DHS

The license holder did not meet the requirements for program outcomes in the following ways: a. The license holder’s written policy did not clearly identify their program outcomes; b. The license holder did not annually evaluate the program’s strengths and weaknesses for calendar years 2023 and 2024, using the following performance indicators: i. Accidents ii. Grievances iii. Results of a resident and family satisfaction survey iv. The program’s outcomes and outcome measures; and v. Critical incidents; d. The license holder’s documentation did not demonstrate their use of the program evaluation reports and findings as a basis to make improvements in its program for calendar years 2023 and 2024; and e. The license holder’s documentation did not demonstrate that at least annually the license holder met with community leaders representing the area where the facility is located to advise the community leaders about the nature of the program, the types of residents served, the results of the services the program provided to residents, the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months.

Violation cited by DHS

The license holder’s staff ratios did not meet requirements to ensure the minimum number of direct care staff that must be present and awake when residents are present and awake is one staff person per 12 residents for the following: a. 1 staff to 18 residents from 4 to 6:30pm on 10/7/2025; and b. 1 staff to 17 residents from 7 to 9am on 10/18/2025.

Violation cited by DHS

The license holder did not meet critical incident reporting requirements in the following ways: a. Incidents that occurred on the following dates met the definition of a critical incident and were not reported to DHS on September 20, 2024, January 12, 2025, March 2 and 6, 2025, and June 30, 2025; and b. Critical incidents that occurred on the following dates were not reported to DHS within ten days: March 2, 2024, May 5 and 19, 2024, September 21, 2024, November 17, 2024, April 12, 2025, and July 7, 2025.

Violation cited by DHS

The license holder’s grievance practices did not meet requirements in the following ways: a. The investigation findings and resulting action taken by the license holder were not documented grievances dated January 24, 2024, June 16 and 29, 2024, and June 1, 2025; and b. The license holder did not follow their written grievance procedure for a grievance filed on May 17, 2025.

Violation cited by DHS

The license holder’s satisfaction survey practices did not meet requirements. The license holder did not survey referring agencies regarding the license holder’s satisfaction with the services.

Violation cited by DHS

Three of twelve personnel files reviewed for requirements governing background study documentation in a children’s residential facility did not meet requirements. The license holder did not document: a. The first date that a staff person began working in the license holder’s facility (personnel file numbered 1); and b. The first date that a staff person had direct contact, as defined in section 245C.02, subdivision 11, with a person served by the license holder’s program (personnel files numbered 1, 2, and 4).

Violation cited by DHS

The license holder did not meet requirements governing the supervision of individuals with a temporary permit from the Board of Behavioral Health and Therapy (personnel file numbered 2). The individual was supervised by a Licensed Alcohol and Drug Counselor assigned by the license holder who also was qualified as a clinical supervisor approved by the Board of Behavioral Health and Therapy; however, the supervision documentation did not demonstrate either of the following: a. Weekly supervision, related to clinical practices, had occurred, and the documentation included the amount and type of supervision; or b. Supervision had occurred and met the requirements of Minnesota Statutes, section 148F.04, subdivision 4.

Violation cited by DHS

Five of twelve personnel files reviewed for requirements governing staff qualifications did not meet requirements in the following ways: a. Documentation did not demonstrate that the staff had been trained in gender-based needs and issues (personnel file numbered 7); and b. The personnel file of an alcohol and drug counselor did not include documentation to demonstrate that the individual had the following: i. An additional 30 hours of classroom instruction in adolescent development (personnel files numbered 1, 2, and 4); ii. At least 150 hours of supervised experience as an adolescent alcohol and drug counselor, either as a student or as an employee (personnel file numbered 1); and iii. Current professional licensure (personnel file numbered 9).

Violation cited by DHS

Eight of nine personnel files reviewed governing orientation training did not meet requirements in the following ways: a. Documentation did not demonstrate that the staff persons and student intern received orientation to the following topics before having unsupervised contact with residents: i. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment (personnel files numbered 2, 5, and 7); ii. Maltreatment of Minors reporting requirements under Minnesota Statutes, sections 260E (personnel files numbered 1, 2, 4, 5, and 7); iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 5, 7, and 10); iv. General and special needs, including disability needs or residents and families served (personnel files numbered 1, 2, 4, 5, 7, and 10); v. Operational policies and procedures (personnel file numbered 5); and vi. Data practices regulations and issues (personnel files numbered 1, 2, 5, and 7); b. Documentation did not demonstrate that within 72 hours of first providing direct contact services, the staff persons and student intern were oriented to the following: i. Vulnerable adults maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 1, 2, and 7); ii. The license holder’s program abuse prevention plan (personnel ...

Violation cited by DHS

Six of six personnel files reviewed governing ongoing training did not meet requirements in the following ways (personnel files numbered 2, 3, 8, 9, 11, and 12): a. Documentation did not demonstrate the staff person received ongoing training to: i. Maltreatment of minors reporting requirements and definitions in Chapter 260E.06 subd 1; and ii. HIV Minimum Standards, annually; and b. Training documentation did not include the name of the entity/person(s) that provided the training. Statute and

Violation cited by DHS

One of three resident files reviewed for requirements governing admission procedures (resident file numbered 2) did not meet requirements. The license holder did not inventory the resident’s personal property, including clothing.

Violation cited by DHS

Three of three resident files reviewed for requirements governing admission screenings (resident files numbered 1 through 3) did not meet requirements in the following ways: a. The screening for sexually abusive behavior was not completed; b. The screening instrument used did not include all components required by the cultural screening tool approved by the commissioner; c. The screening to determine the resident’s gender-based needs was not completed; and d. There were no documented inquiries and results of the inquiries regarding the degree to which the resident’s family desired to be involved during the resident’s stay in the facility.

Violation cited by DHS

One resident file reviewed for requirements governing program services (resident file numbered 1) did not meet requirements. The license holder did not review the emergency plan with the resident at least every six months.

Violation cited by DHS

One of three resident files reviewed for requirements governing treatment plans (resident file numbered 3) did not meet requirements. The license holder did not begin to develop a treatment plan within 10 days of admission.

Violation cited by DHS

Three of three resident files reviewed for requirements governing required treatment services and documentation did not meet requirements. The license holder did not document the amount of each service the resident had received weekly into the residents’ files for the following weeks reviewed: a. January 12 through 18, 2025, and March 16 through 22, 2025 (resident file numbered 1); b. June 8 through 14, 2025, and September 14 through 20, 2025 (resident file numbered 2); and c. January 19 through 25, 2025, and February 9 through 15, 2025 (resident file numbered 3).

Violation cited by DHS

Three of three resident files reviewed for requirements governing the administration of medications (resident files numbered 1 through 3) did not meet requirements. The license holder did not: a. Contact a newly admitted residents’ prescribing medically licensed person to verify the symptoms the medication would alleviate and the symptoms that would warrant a consultation with the physician (resident files numbered 1 through 3); b. Document attempts to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident files numbered 1 through 3); c. Document and follow the prescribing physician’s directions for administering a medication used by the resident for a medication started on February 21, 2025 (resident file numbered 3); and d. Keep records for a resident who received prescription drugs at the facility and note the quantity initially received from the pharmacy (resident files numbered 1 and 2).

Violation cited by DHS

One of two resident files reviewed for requirements governing no eject (resident file numbered 3) did not meet requirements in the following ways: a. Documentation did not demonstrate that before the license holder discharged a resident who had not yet reached their treatment plan goals, the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge and permit the resident an opportunity to continue to receive services; b. The license holder exceeded the five allowable working days to complete the review process; and c. Documentation of the reasons that warranted discharge was inconsistent. The license holder maintained two discharge summaries, one completed upon discharge, the other modified months later, and the information included in each was not consistent.

Violation cited by DHS

The license holder was previously found in violation of the same rule in a correction order DHS issued on July 2, 2021.

Violation cited by DHS

Two of two resident files reviewed for requirements governing transition services plan (resident files numbered 4 and 5) did not meet requirements in the following ways: a. The license holder did not develop a plan with input from the resident, the resident’s family members, if appropriate, the providing school district, and the persons who will provide support services to the resident upon release; b. The license holder did not document providing a copy of the plan to the resident or to the residential treatment facility that the resident would attend or was placed at after release; and c. The transitional services plan did not include the following: i. A budget plan and a description of the resident’s financial and employment status; ii. Health services; and iii. Personal safety needs.

Violation cited by DHS

The license holder did not meet requirements of ensuring basic rights in the following ways: a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as, a designated amount of time, in hours, to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds, and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments that are meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the individual treatment plan. b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2021, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and

Violation cited by DHS

The license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior. All of the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours”, and the description of a “service hour” and other consequences that would be applied, were not indicated in writing to the resident in the Resident Handbook: Behavior and

Violation cited by DHS

The license holder did not meet requirements for spirituality services and counseling. The license holder considered the residents’ lack of attendance at religious services as a basis for privileges in the facility. According to the Resident Handbook (LASH 330 & 840) and resident (R2 through R4) and staff (SP2 and SP3) investigative interviews, religious services are considered a type of scheduled programming and skipping or refusing programming leads to a consequence of “service hours” and loss of privileges.

Violation cited by DHS

The license holder did not meet requirements of ensuring basic rights in the following ways: a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as, a designated amount of time, in hours, to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds, and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments that are meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the individual treatment plan. b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2021, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and

Violation cited by DHS

The license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior. All of the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours”, and the description of a “service hour” and other consequences that would be applied, were not indicated in writing to the resident in the Resident Handbook: Behavior and

Violation cited by DHS

The license holder did not meet requirements for spirituality services and counseling. The license holder considered the residents’ lack of attendance at religious services as a basis for privileges in the facility. According to the Resident Handbook (LASH 330 & 840) and resident (R2 through R4) and staff (SP2 and SP3) investigative interviews, religious services are considered a type of scheduled programming and skipping or refusing programming leads to a consequence of “service hours” and loss of privileges.