Newport Academy – St. Cloud

Violation cited by DHS

The license holder did not monitor the development and implementation of their restrictive procedures plan to ensure the use of physical holding was used only as permitted in a resident’s treatment plan. The license holder’s Behavior Management and Emergency Safety Intervention Policy stated that the need for manual restraints is determined in advance on an individual basis by the client’s treatment team and documented in the client’s treatment plan as an intervention to prevent immediate or imminent injury to the client or to others and the use of holds will only be used as permitted in the resident’s treatment plan. Client files reviewed (C1 and C3) included treatment plans that stated, “this facility does not utilize physical restrictive procedures to protect the resident from imminent danger to self or others….” However, the licensed facility is certified to utilize restrictive procedures and was found to have utilized a physical hold with clients C1 and C3 on March 28, 2026, according to client file documentation.

Violation cited by DHS

One of two critical incidents reviewed was not submitted to the Department within ten days of the occurrence. On March 24, 2026, three clients (C1-C3) ran away from the facility, climbed into dumpsters, and ingested unknown items. Staff called 9-1-1 and took C1 to an emergency room after s/he repeatedly vomited. On April 4, 2026, eleven days later, the license holder submitted a DHS Critical Incident Report to the Department for this occurrence.

Violation cited by DHS

One of ten staff (S1) records reviewed did not meet annual training requirements. The license holder did not ensure the maltreatment of minors reporting requirements and definitions in chapter 260E to each mandatory reporter, as described in section 260E.06, subdivision 1 was completed annually. The license holder provided documentation that in 2024, S1 received training on the maltreatment of minors reporting requirements but S1 did not receive this same training annually thereafter.

Violation cited by DHS

The license holder did not monitor the development and implementation of their restrictive procedures plan to ensure the use of physical holding was used only as permitted in a resident’s treatment plan. The license holder’s Behavior Management and Emergency Safety Intervention Policy stated that the need for manual restraints is determined in advance on an individual basis by the client’s treatment team and documented in the client’s treatment plan as an intervention to prevent immediate or imminent injury to the client or to others and the use of holds will only be used as permitted in the resident’s treatment plan. Client files reviewed (C1 and C3) included treatment plans that stated, “this facility does not utilize physical restrictive procedures to protect the resident from imminent danger to self or others….” However, the licensed facility is certified to utilize restrictive procedures and was found to have utilized a physical hold with clients C1 and C3 on March 28, 2026, according to client file documentation.

Violation cited by DHS

One of two critical incidents reviewed was not submitted to the Department within ten days of the occurrence. On March 24, 2026, three clients (C1-C3) ran away from the facility, climbed into dumpsters, and ingested unknown items. Staff called 9-1-1 and took C1 to an emergency room after s/he repeatedly vomited. On April 4, 2026, eleven days later, the license holder submitted a DHS Critical Incident Report to the Department for this occurrence.

Violation cited by DHS

One of ten staff (S1) records reviewed did not meet annual training requirements. The license holder did not ensure the maltreatment of minors reporting requirements and definitions in chapter 260E to each mandatory reporter, as described in section 260E.06, subdivision 1 was completed annually. The license holder provided documentation that in 2024, S1 received training on the maltreatment of minors reporting requirements but S1 did not receive this same training annually thereafter.

Violation cited by DHS

The license holder did not notify the commissioner by the tenth business day after a change to the Authorized Agent was made, nor did the license holder provide additional information requested by the commissioner. On June 2, 2025, DHS was informed that the license holder’s delegated Authorized Agent needed to be updated. DHS contacted the license holder on June 11, 2025, and August 4, 6, and 13, 2025, to provide instructions and the appropriate forms to complete the change, however, the license holder has yet to provide DHS with the required forms and information that has been requested to complete the change.

Violation cited by DHS

The license holder’s Emergency Plan, 7.2 Emergency Response Plan, did not meet requirements in the following ways: a. The plan’s procedure for responding to the disappearance of a resident required the use of a staff notification system and for other staff persons to respond. The procedure did not describe what actions staff should take if other staff could not respond and it did not describe what the staff notification system consisted of; b. The plan did not identify actions the staff must take for other emergency situations that may require a law enforcement or other emergency response; and c. The plan did not include the “Crisis Response Code Call Protocol,” a practice identified in an internal review completed on April 1, 2024.

Violation cited by DHS

The license holder’s admission policy did not meet the requirements for rules governing adolescent resident chemical dependency treatment. The admission policy did not include 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, or that all denials of admission that involve the commission of a crime against a license holder’s property must be reported to a law enforcement agency.

Violation cited by DHS

The license holder’s program abuse prevention plan did not meet requirements. The assessment of the physical plant did not include: a. An assessment of the physical plant that includes fire escapes and outer buildings; and b. An assessment of the environment that includes the location of the program in a particular neighborhood or community and the type of grounds and terrain surrounding the building. The assessment did not include the “look-out.”

Violation cited by DHS

The license holder’s facility rules did not include the following: a. All consequences that will be applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior, including behaviors that might warrant 1:1 supervision; and b. The circumstances that will result in the use of restrictive procedures are not included in the rules provides to the residents.

Violation cited by DHS

The license holder did not monitor the implementation of their policies and procedures. The program abuse prevention plan stated the program would be staffed with 1 staff for every 6 residents. Documentation indicated this ratio was not maintained in practice.

Violation cited by DHS

The license holder did not ensure the residents’ rights according to Minnesota Statutes, section 144.651, subdivision 23, were protected. Residents were responsible for performing labor for the facility without the labor being therapeutic or appropriately goal related.

Violation cited by DHS

The license holder’s admission process did not meet requirements in the following ways: a. There was no documentation to demonstrate that the license holder determined the following conditions were met before allowing a resident to admit to the license holder’s program: i. The resident was screened by a mental health professional using a process equivalent to the required process identified in Minnesota Statutes, section 245.4885; ii. The developmental and mental health needs of the resident could be met by the program; and iii. The resident met the admission criteria in the license holder’s admission policy; and b. The admission process allowed for the admission authority to come from various individuals who were not directly involved with the program itself, rather the program’s organization. Furthermore, the admission process did not include the program’s direct involvement to assess the current capacity of the program, including the staff and other residents, to determine whether the program could meet the resident’s needs.

Violation cited by DHS

The license holder did not have documentation to demonstrate that they met the requirements governing outcome evaluations: a. The license holder did not have documentation demonstrating that they annually evaluated the program’s strengths and weaknesses for the year of 2022, and the evaluation for 2023 was missing the following performance indicators: i. Accidents; ii. The use of restrictive procedures; iii. Grievances; iv. Adverse findings and allegations of maltreatment; v. Outcomes and outcome measures; and vi. Critical incidents; b. The license holder did not have documentation that they used the program evaluations reports and findings as a basis to make improvements in its programs; and c. The license holder’s 2022 and 2023 documentation of annual meetings with area community leaders did not demonstrate that they advised community leaders on the nature of their program, the types of residents served, and the results of the services provided to the residents.

Violation cited by DHS

The license holder’s documentation of their reviews of the use of restrictive procedures did not meet requirements in the following ways: a. The quarterly reviews for 2022 Quarter 4 and 2023 Quarter 1 were not completed; b. The quarterly reviews completed for 2023 and 2024 did not consider: i. Any patterns or problems indicated by similarities in the time of day, day of the week, duration of use, individuals involved (exclusive of 2024 Quarter 2), or other factors associated with the use of restrictive procedures; and ii. Any staff injuries resulting from the use of restrictive procedures; and c. The annual written review of the use of restrictive procedures was not completed for the year 2022 and did not address the entire year’s data for 2023.

Violation cited by DHS

The license holder’s staffing plan did not identify the assignments of all facility staff.

Violation cited by DHS

The license holder did not have documentation to demonstrate that a mental health professional provided weekly face-to-face clinical supervision to all staff providing program services to clients for the weeks beginning March 24, 2024, and September 1, 2024. For the week beginning March 24, 2024, 14 staff did not attend clinical supervision, and for the week beginning September 1, 2024, 25 staff did not attend.

Violation cited by DHS

The license holder did not follow requirements governing grievances for grievances filed in the years of 2023 and 2024. A total of 11 grievances were reviewed for the year 2023, and 21 for 2024: a. A person filing a grievance did not receive a response within five days for 8 grievances received in 2023 and 1 in 2024; and b. The license holder did not document investigation findings and resulting actions taken by the license holder for 15 grievances received in 2024.

Violation cited by DHS

In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

Violation cited by DHS

The license holder did not meet all requirements governing satisfaction surveys. The satisfaction surveys did not include gathering feedback on the positive and negative effects on the resident and the resident’s family of the treatment offered to the resident.

Violation cited by DHS

In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same statute and rule.

Violation cited by DHS

One personnel file reviewed for rules governing alcohol and drug counselor staff qualifications did not meet requirements. The license holder’s personnel file did not include documentation of the staff person’s qualifications to provide adolescent treatment services (personnel file numbered 6).

Violation cited by DHS

Eight of nine personnel files reviewed for rules governing orientation training did not meet requirements in the following ways: a. The license holder did not ensure that staff who have direct contact with residents attend and successfully complete orientation training before having unsupervised contact with residents that included: i. Emergency procedures including evacuation routes, emergency telephone numbers, severe storm and tornado procedures (personnel file numbered 10); ii. Maltreatment of minors reporting requirements under Minnesota Statutes, sections 260E (personnel files numbered 8 and 10); iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 8 and 10); iv. General and special needs, including disability needs, of residents and families served (personnel files numbered 1, 2, 3, 6, 8, and 10); v. Operational policies and procedures (personnel file numbered 10); and vi. Data practice regulations and issues (personnel files numbered 8 and 10). b. The license holder did not have documentation to support that the following orientations and trainings were provided to staff and volunteers: i. Culturally competent care (personnel file numbered 10); ii. Racial bias and racism issues (personnel file numbered 10); iii. Gender issues, including the psychosocial development of boys and girls (personnel file numbered 10); iv. Sexual orientation (personnel file ...

Violation cited by DHS

Six of twelve personnel files reviewed for requirements governing staff training did not meet requirements. The license holder did not have documentation to demonstrate that they: a. Required staff to undergo training in the specific mode of administration of emergency overdose treatment used at the program which may include intranasal administration, intramuscular injection, or both (personnel file numbered 3); and b. Provided training to program staff related to their duties in implementing the program’s policies and procedures necessary to maintain compliance with licensing requirements under Minnesota Statutes and Minnesota Rules. The “shadow checklist” was not completed (personnel files numbered 1, 6, 7, 11, and 12).

Violation cited by DHS

Four of four personnel files reviewed for requirements governing ongoing staff training did not meet requirements in the following ways: a. The license holder did not have documentation of staff receiving the following trainings annually: i. Vulnerable adults maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 4, 5, 7, and 11); ii. The program abuse prevention plan (personnel files numbered 4, 5, 7, and 11); iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 4); iv. The maltreatment reporting requirements and definitions in chapter 260E (personnel files numbered 4, 5, 7, and 11); and v. HIV minimum standards (personnel files numbered 4, 5, and 11); and b. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 4, 5, 7, and 11). Statute and

Violation cited by DHS

Seven of twelve personnel files reviewed for rules governing individual staff development and evaluation plans did not meet requirements. The license holder did not ensure that an annual individual staff development and evaluation plan was developed and implemented (personnel file numbered 10), and the plan was not developed within 90 days after the staff person began employment and at least annually thereafter (personnel files numbered 3, 4, 7, 9, 12, and 13).

Violation cited by DHS

Four of four resident files reviewed for rules governing resident information did not meet requirements. The licensor holder did not document in the resident’s file the resident’s tribal affiliation (resident files numbered 1, 2, 4, and 5) or a description of strengths and assets of the resident (resident files numbered 4 and 5).

Violation cited by DHS

Eleven of eleven resident files reviewed for rules governing admission criteria did not meet requirements. Before or at the admission of a resident, the license holder did not document whether the resident is a danger to the resident’s self or others, whether the program is able to meet the resident’s cultural emotional, educational, mental health, or physical needs (resident files numbered 1 through 5 and 8 through 13).

Violation cited by DHS

Four of four resident files reviewed for rules governing admission procedures did not meet requirements in the following ways: a. The license holder did not inventory a resident’s personal property upon admission (resident file numbered 5) or the inventory was not signed by the resident or staff member (resident file numbered 4); b. The license holder did not tell the resident’s parent, guardian, or custodian within a reasonable time after admission that information on the resident’s rights was available (resident files numbered 2 and 4); c. Facility appeal procedures were not made available to a resident at the time of admission (resident files numbered 1 through 4); and d. Residents receiving substance use treatment did not receive orientation to the HIV minimum standards and that educational information concerning treatment options of opioid addiction was provided (resident files numbered 1 and 4). Statute and

Violation cited by DHS

Two of two resident files reviewed for rules governing vulnerable adult orientation did not meet requirements. There was no documentation that a new adult receiving services from the program received orientation to the internal and external reporting polices regarding maltreatment of vulnerable adults and the program abuse prevention plan (resident files numbered 5 and 7) or that the license holder sought consent to the discloser of suspected maltreatment from the resident, a guardian, conservator, or legal representative (resident file numbered 7).

Violation cited by DHS

Five of six resident files reviewed for rules governing the initial services plan of a resident receiving substance use treatment did not meet all requirements. The initial services plan did not address any immediate health and safety concerns (resident files numbered 1, 9 , 11, 12, and 13), suggestions for the client during the team between their intake and first treatment session (resident file numbered 1), or what issues are to be addressed in the first treatment sessions (residents files numbered 1, 9, and 11).

Violation cited by DHS

Four of four resident files reviewed for rules governing admission screenings did not meet requirements in the following ways: a. The health screening was not completed within 24 hours of admission (resident files numbered 1, 2, and 4); b. The substance use disorder screening was not completed within six days of admission (resident files numbered 2 and 5); c. The screening for sexually abusive behavior was not completed within six days of admission (resident file numbered 5); d. The vulnerability assessment was not completed within 6 days of admission (resident file numbered 5); e. The cultural screening was not completed (resident file numbered 5); f. The gender specific needs screening was not completed (resident file numbered 5); and g. The screenings did not include inquiries and the results of the inquiries regarding the degree to which the resident’s family desires to be involved during the resident’s stay at the facility (resident files numbered 1, 2, 4, and 5).

Violation cited by DHS

Four of four resident files reviewed for rules governing program services did not meet requirements. The license holder did not have documentation to demonstrate that they offered services to support the resident and family in learning how to plan and participate in recreation and leisure activities (resident files numbered 1, 2, 4, and 5) or vocational skill development (resident files numbered 1, 2, and 5).

Violation cited by DHS

Four of four resident files reviewed for rules governing treatment plans did not meet requirements. The license holder did not include the use of psychotropic medications in the resident’s individual treatment plan (resident files numbered 1, 2, 4, and 5).

Violation cited by DHS

Four of four resident files reviewed for rules governing service plan reviews did not meet requirements. There was not documentation to show that the individual abuse prevention plan for a vulnerable adult was reviewed as a part of the service plan review (resident files numbered 5 and 7) and the individual treatment plan was not reviewed by an alcohol and drug counselor every two weeks (resident files numbered 1 and 4). Statute and

Violation cited by DHS

Two of four resident files reviewed for rules governing health care did not meet requirements. The license holder did not have documentation to support that they contacted a newly admitted resident’s prescriber to verify information regarding the resident’s prescriptions (resident file numbered 2) or that they noted the quantity initially received from the pharmacy for a resident who received prescription drugs at the facility (resident file numbered 4).

Violation cited by DHS

Four of four resident files reviewed for rules governing psychotropic meds did not meet requirements in the following ways: a. The license holder did not have documentation that they monitored for side effects for residents prescribed a psychotropic medication at least weekly for the first six weeks and then quarterly thereafter (resident files 1 and 2) using standardized checklists or rating scales (resident files numbered 1, 2, 4, and 5); b. The license holder did not have documentation to demonstrate that they conducted a psychotropic medication review at least monthly for the first six months and at least quarterly thereafter (resident files numbered 1, 2, 4, and 5).

Violation cited by DHS

Three of four resident files reviewed for rules governing informed consents did not meet requirements in the following ways: a. The license holder did not have documentation that they obtained consent before any nonemergency administration of psychotropic medication (resident file numbered 2); b. The license holder did not have documentation to demonstrate that the following information was communicated both orally and in writing to the resident’s legal guardian and the resident regarding the prescribed psychotropic medication (resident files numbered 4 and 5): i. The diagnosis and level of severity of the symptoms and behaviors for which the medication is prescribed; ii. Expected benefits of the medication; iii. Pharmacological and nonpharmacological treatment options available and the course of the condition with and without the treatment options; iv. Specific information about the medication to be used, including the generic and commonly known brand name, the route of administration, the estimated duration of therapy, and the proposed dosage range or maximum dose; v. The more frequent and less frequent but serious side effects of the medication, including how the risks and possible side effects must be managed; vi. An explanation that consent may be refused or withdrawn at any time and that consent is time limited and automatically expires in 30 days for verbal consent and annually for written consent; and vii. The names, addressed, and telephone numbers of appropriate ...

Violation cited by DHS

Three of three resident files reviewed for rules governing the use of restrictive procedures did not meet requirements. The license holder did not meet requirements in these ways: a. There was not documentation that staff contacted the mental health professional or program director to inform them of the use of physical holding no later than 30 minutes after initiating the physical hold for the following dates: i. March 31, 2024 (resident file numbered 3); and ii. July 7, 2024 (resident file numbered 6). b. The staff person that implemented the emergency use of physical holding on March 31, 2024, did not document its use immediately after the incident concluded; the incident was not documented as a restrictive procedure (resident file numbered 3); and c. The license holder did not have documentation that an administrative review was completed within three working days after the use of the restrictive procedures on April 12, 2024, and April 25, 2024 (resident files numbered 3 and 8).

Violation cited by DHS

Two of two resident files reviewed for rules governing no-ejects did not meet requirements. The license holder did not have documentation that during the no-eject review process the license holder determined whether the license holder, treatment team, interested persons, or the resident could develop additional strategies to resolve issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder (resident files numbered 4 and 6).

Violation cited by DHS

Three of four resident files reviewed for rules governing discharge procedures did not meet requirements. The license holder did not have documentation of a signed receipt at discharge by the resident that all of their personal property was returned (resident files numbered 1, 4, and 5).

Violation cited by DHS

Three of four resident files reviewed for rules governing transition services plans did not meet requirements. There was not documentation that the plan considered the environment into which the resident was discharging to and recommendations for how the resident may deal with issues and potential challenges within that environment (resident files numbered 4, 5, and 8) or that a copy of the plan was given to the resident (resident file numbered 8).

Violation cited by DHS

Eight of eight resident files reviewed for rules governing discharge documentation did not meet requirements. The license holder did not document: a. The extent to which a resident’s stay in the facility met the goals and objectives identified in the resident’s treatment plan (resident file numbered 5); b. The services identified in the resident’s treatment plan that were provided to the resident directly by the license holder and the services that were provided by a provider other than the license holder and who provided the services (resident files numbered 1, 4, 9, 10, 11, and 12); c. The extent to which the services provided the resident contributed to achieving the goals and objectives identified in the resident’s treatment plan (resident files numbered 4, 5, 9, 10, 11, and 12); d. The development of a discharge plan at least ten days prior to discharge that includes arranging for appropriate follow up care in the community and written notification of the discharge to the resident’s legal guardian (resident file numbered 5).

Violation cited by DHS

The license holder’s restrictive procedures policy did not address prone positions or contraindicated physical restraints. The license holder was not assessing residents for any contraindications due to known medical or psychological conditions. Request for Reconsideration. You submitted a letter and supporting documentation to support your belief that the citation was incorrect. Reconsideration Determination. Under Minnesota Statutes, section 245A.211, subdivision 3, paragraph (b), a license holder must not use a prone restraint on any person receiving services in a program, except in specified instances which includes that if a person rolls into a prone position during the use of a restraint, the person must be restored to a nonprone position as quickly as possible. Under subdivision 4, a license holder must not implement a restraint on a person receiving services in a program in a way that is contraindicated for any of the person’s known medical or psychological conditions. Prior to using restraints on a person with known medical or psychological conditions that restraints are contraindicated for, the license holder must document the contraindication and the type of restraints that will not be used on the person based on this determination. After further review of the file and of the information provided by the license holder, the Commissioner has determined the program met the statutory requirements regarding citation 5, and the citation should be rescinded. Disposition ...

Violation cited by DHS

The license holder’s operational policies and procedures did not describe how the license holder will provide a resident with timely access to medical services to ensure a resident’s basic right to adequate medical care is protected. The Health & Hygiene policy did not identify when medical services would be provided.

Violation cited by DHS

The license holder failed to monitor the implementation of procedures identified in the license holder’s Medication Management policy for recording the administration of medications to residents. The policy indicated that a Medication Administration Record (MAR) will document all prescription and non-prescription medications administered to residents. An incident report and nursing shift note dated December 7, 2022, documented that a resident (R1) was administered Tylenol in error, however, it was not recorded as administered on the resident’s medication administration record.