PrairieCare Residential Services

Violation cited by DHS

The license holder’s service delivery plan did not meet requirements. The plan did not describe how the program provides services according to the following ways: a. That the following staff be available 24 hours a day and seven days a week to provide care within the scope of their practice: i. A registered nurse or licensed practical nurse; and ii. Other licensed clinical staff. b. Contacting and facilitating outreach to each resident’s family members, including the resident’s siblings, and must document outreach to the resident’s family members in the resident’s file, including the contact method and each family member’s contact information; c. Recording and maintaining the contact information for all known biological family members and fictive kin of the resident; d. Documenting in the resident’s file how the program integrates family members into the treatment process for the resident, including after the resident’s discharge from the program, and how the program maintains the resident’s connections to the resident’s sibling; e. Discharge planning and family-based aftercare support to each resident for at least six months after the resident’s discharge from the program; and f. When providing aftercare to a resident, having monthly contact with the resident and the resident’s caregivers to promote the resident’s engagement in aftercare services and to regularly evaluate the family’s needs.

Violation cited by DHS

The license holder’s time-out policy did not include the following required components: a. Time-outs must be used under the direction of a mental health professional, facility director, or the program manager; b. The use of time-out must be consistent with the resident’s treatment plan; c. The treatment team must include and document the review of the use of time-out for each resident during the review of the resident’s treatment plan; d. Staff must document the use of time-out in the resident’s record and include the following information: i. The factors or circumstances which caused the need for the use of time-out; ii. The resident’s response to the time-out; iii. The resident’s ability to de-escalate during the time-out procedure; and iv. The resident’s ability to maintain acceptable behavior after the time-out.

Violation cited by DHS

The license holder’s restrictive procedure plan did not meet requirements. The plan did not include the following items: a. A description of the training that staff who use restrictive procedures must have prior to staff implementing the emergency use of restrictive procedures; b. A license or certification holder must not use a prone restraint on any person receiving services in a program, except 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; and c. How the license holder will address and document contraindicated physical restraints.

Violation cited by DHS

The license holders plan for transfer of records and clients upon closure did not meet requirements. The plan was not reviewed and signed annually by a controlling individual of the program for the year of 2025.

Violation cited by DHS

The license holders provision of trauma informed care did not meet requirements. The license holder implemented “room-time” for all residents, where they were required to remain in their rooms for 30 to 60 minutes, three to four times per day. Through interviews with staff, it was determined that this practice was not modified to respond to the effects of trauma on the person receiving services, and did not acknowledge the effects of trauma on a person receiving services.

Violation cited by DHS

For two of two weeks reviewed, the license holder’s practice of clinical supervision did not meet requirements in the following ways: a. For December 23 through 29, 2024, five of thirty-two staff who provided program services did not receive clinical supervision from a mental health professional; and b. For July 7 through 13, 2025, nine of thirty-six staff who provided program services did not receive clinical supervision from a mental health professional.

Violation cited by DHS

License holder was cited for similar violations in a Correction Order dated April 8th, 2022. Resident Files

Violation cited by DHS

Four of four resident files reviewed for requirements governing resident information did not meet requirements in the following ways: a. Admission documentation regarding the following did not occur upon or within five working days after admission (resident file numbered 1): i. Legal authority for a resident’s placement; ii. Date and time of admission; iii. Race or cultural heritage, language the resident speaks and write, tribal affiliation, if any; iv. Description of presenting problems: including medical problems, circumstances leading to admission, mental health concerns, safety, concerns including assaultive behavior, victimization concerns; v. description of assets and strengths of the resident and, if available, related information from the resident, resident's family, and concerned persons in the resident's life; and vi. spiritual or religious affiliation of the resident and the resident's family b. The resident file did not have documentation demonstrating that the license holder recorded and maintained the contact information for all known biological family members and fictive kin of the resident (resident files numbered 1, 2, 3, and 4).

Violation cited by DHS

Four of four resident files reviewed for requirements governing admission criteria did not meet requirements in the following ways: a. When public funds were not used to pay for services, there was no documentation to demonstrate that the resident was screened by a mental health professional using a screening process that is equivalent to that required by Minnesota Statutes, section 245.4885, subdivision 1, before admission (resident files numbered 1); and b. There was no documentation to demonstrate that the license holder determined their program could meet the developmental and mental health needs of the resident (resident files numbered 1, 2, 3, and 4).

Violation cited by DHS

Four of four resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 2, 3, and 4). Each resident was not provided with a complete description of the applicable programs and activities available to residents in the facility.

Violation cited by DHS

The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

Violation cited by DHS

Four of four resident files reviewed for requirements governing admission screenings did not meet requirements (resident files numbered 1, 2, 3, and 4) in the following ways: a. The sexually abusive behavior screening, vulnerability assessment, and cultural screening did not include all of the required components b. Documentation about the degree to which the resident’s family desires to be involved during the residents stay at the facility did not include the family’s response. c. There was no documentation to demonstrate a trauma-specific screening was completed.

Violation cited by DHS

Two of two resident files reviewed for requirements governing chemical health education did not meet requirements (resident files numbered 1 and 2). There was no documentation to demonstrate that the license holder provided education about chemical health to the residents who have had a problem related to inappropriate chemical use, but who do not have a sufficient chemical use history to refer to treatment.

Violation cited by DHS

Four of four resident files reviewed for requirements governing program services did not meet requirements in the following ways: a. The license holder did not facilitate participation of the resident’s family members in their treatment program, consistent with their best interests (resident files numbered 1 and 2); and b. The license holder did not contact and facilitate outreach to each resident’s family members, including the resident’s siblings, and document outreach to the resident’s family members in the resident’s file, including contact method and each family member’s contact information (resident files numbered 1, 2, 3, and 4).

Violation cited by DHS

Four of four client files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The individual treatment plan was not completed within 10 working days of admission (resident files numbered 1, 2, and 4); b. The plan did not identify a schedule for accomplishing treatment goals and objectives (resident files numbered 1 and 2); c. The use of psychotropic medication was not included in the resident’s individual treatment plan (resident files numbered 2); d. The plan did not include a description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident files numbered 3 and 4); and e. A mental health professional did not document involvement in the treatment planning process by signing the individual treatment plan (resident file numbered 1).

Violation cited by DHS

Two of four resident files reviewed for requirements governing service plan reviews did not meet requirements (resident files numbered 1 and 4). There was no documentation to demonstrate the use of time-out for each resident was reviewed during the review of their treatment plan. in the following ways:

Violation cited by DHS

One of four resident files reviewed for requirements governing health care did not meet requirements (resident file numbered 1). There was no documentation to demonstrate that the prescription medication belonging to the resident was given to the resident's parent or legal guardian upon the resident's release according to a pharmacy-approved plan.

Violation cited by DHS

Four of four resident files reviewed for requirements governing psychotropic medications did not meet requirements in the following ways: a. There was no documentation identifying a list of possible side effects for a resident prescribed a psychotropic medication (resident files numbered 1, 2, 3, and 4); and b. The license holder did not document a psychotropic medication review at least monthly for the first six months (resident files numbered 1, 3, and 4).

Violation cited by DHS

Two of four resident files reviewed for requirements governing informed consent for the administration of psychotropic medication did not meet requirements in the following ways: a. When oral consent was obtained, an explanation for why written informed could not be initially obtained was not documented. All psychotropic medications were listed on one informed consent form and the line for the explanation was left blank (resident files numbered 1 and 2); and b. The license holder did not provide documentation demonstrating that they provide the required information in writing to the resident’s parents, the resident’s legal representative, and, to the extent possible, the resident (resident file numbered 1).

Violation cited by DHS

Two of two resident files reviewed for requirements governing time-out procedures did not meet requirements in the following ways: a. The use of time out was not documented in the resident file (resident file numbered 1); and b. Documentation of a time-out implemented on 04/02/2025 did not include the resident’s ability to de-escalate during the time-out or their response to the time-out (resident file numbered 4).

Violation cited by DHS

One of three resident files reviewed for requirements governing restrictive procedures did not meet requirements (resident file numbered 5) in the following ways: a. Documentation did not demonstrate that an immediate intervention was necessary to protect the resident or others from physical harm, for a physical hold implemented on 06/25/2025; and b. Documentation did not demonstrate that the mental health professional was contacted to inform them about the use of physical holding and to ask for permission to use physical holding.

Violation cited by DHS

One of two resident files reviewed for requirements governing no eject discharges did not meet requirements (resident file numbered 1) in the following ways: a. Documentation did not demonstrate that the license holder conferred with other interested persons to review the issues involved in the decision, before discharging the resident who had not reached their treatment plan goals; and b. Documentation did not identify whether any additional strategies could be developed to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder.

Violation cited by DHS

Four of five resident files reviewed for requirements governing discharge did not meet requirements in the following ways: a. There was no documentation to demonstrate that all of the resident’s personal property was returned to the resident (resident files numbered 1 and 4); b. The transition services plan documentation did not demonstrate that the plan was developed with input from the resident’s family members (resident file numbered 6); and c. The license holder did not document the extent to which the resident’s stay in the facility met the goals and objectives identified in the treatment plan (resident files numbered 3, 4, and 6).

Violation cited by DHS

Three of four resident files reviewed for requirements governing aftercare did not meet requirements (resident files numbered 1, 3, and 4). There was no documentation to demonstrate family-based aftercare support was provided to the resident at least monthly.

Violation cited by DHS

Six of six personnel files reviewed for requirements governing ongoing training did not meet requirements (personnel files numbered 1, 2, 3, 4, 5, and 6) in the following ways: a. For calendar year 2023, there was no documentation to demonstrate staff were trained on the impacts of culture, race, gender, and sexual orientation on individual resident’s behavioral health and experiences of trauma annually; and b. The license holder did not document the name of the entity that provided the training. Statute and

Maltreatment determined as to physical abuse of an alleged victim by a staff person.

A. Maltreatment: Facility video from the incident on November 23, 2023, recorded the entire incident between the AV and the SP. After the AV refused to give back a video game controller to the SP. The AV was shoved toward a bean bag chair in the process of taking the controller back and the AV proceeded to lunge at the SP. Both the AV and the SP threw punches at one another and despite attempts by other staff persons to separate the two, the AV and the SP continued their physical aggression against one another. In the process of the incident, the SP punched the AV in the back of the head, the AV pulled the SP’s hair out, and the AV broke the SP’s glasses. Despite efforts by P1 and another staff person to bring the altercation to an end, it did not end until the SP placed the AV in a headlock and P1 managed to separate and keep them separated. The SP, the AV, P1, and P2 provided mostly consistent information regarding their recollection of the incident. The SP and P1 stated that the AV used derogatory terms toward the SP and other residents; P2 confirmed that the AV liked to use derogatory terms toward others at the facility. Given that the video of the incident showed the AV and the SP traded punches with each other in addition to the SP putting the AV in a headlock, there was a preponderance of the evidence that the SP engaged in conduct that was not accidental causing physical and threatened injury to the AV. It was determined that physical abuse occurred (any physical ...

Violation cited by DHS

The license holder’s practice for maltreatment of minors internal review did not meet requirements. The license holder did not complete an internal review within 30 calendar days when the facility knew an external report of alleged or suspected maltreatment had been made. The license holder was informed of the alleged maltreatment on August 29, 2022 and did not complete an internal review until December 16, 2022. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the practice for internal reviews meets all applicable requirements. If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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. 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 ...