raw_content:
June 20, 2025

Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud

236 Clifton Avenue

Minneapolis, MN 55403-3466

License Number: 1106751 (CRF) Facility location:

Report Number: 202500946

CORRECTION ORDER

Dear Daniel Pfarr:

The Department of Human Services (DHS) conducted a maltreatment investigation of 180 Degrees St. Cloud regarding a report of alleged neglect. DHS investigators completed a site visit at the facility on February 20, 2025. The disposition of the investigation report concluded a determination of maltreatment as to neglect of an alleged victim by a staff person. Additionally, the investigation resulted in two violations of licensing rules and statutes. As a result, DHS is issuing this order which requires you to take the corrective action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

Standards reviewed

This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential care under Minnesota Rules, parts 2960.0010 through 2960.0120; shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530; the Family First Preservation Services Act under Minnesota Statutes, section 245A.25; and the Maltreatment of Minors Act under Minnesota Statutes, section 260E.

Licensing Violations

DHS determined that your program failed to follow the standard(s) described below.

PRACTICES

1. Violation: The license holder failed to submit a critical incident report to DHS Licensing within ten days. An incident dated May 25, 2024, met the definition of a critical incident but was not reported.

Citation: Minnesota Statues, section 245A.25, subdivision 3, paragraph (h) and subdivision 5, paragraph

(f) and 245A.65, subdivision 3 and 245A.66, subdivision 4 and Minnesota Rules part 2960.0100, subpart 3, items A and B and subpart 5 and 2960.0150, subpart 4, items B and D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that critical incident reporting meets all applicable requirements.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

RESIDENT FILES

2. Violation: A resident (R) file reviewed during the investigation did not meet requirements for governing health care services. There was no documentation to demonstrate that the license holder contacted the resident’s prescriber to verify the following information regarding prescribed medication:

a. The symptoms the medication will alleviate; and

b. The symptoms that would warrant consultation with the 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 that health care services meet all applicable requirements.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023, and in Correction Orders proceeding this order dated February 21 and November 25, 2024.

If you fail to correct the violations specified in the Correction Order, 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.

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:

Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155

Questions

If you have any further questions regarding this investigation, you may contact Samantha Wueste, Senior Investigator, at 651-431-2278. If you have any questions regarding compliance with this Correction Order or applicable rules, you may contact your licensor, Maddy Gilbertson, Senior Licensor, at 651-431-4585.

Sincerely,

Samantha Wueste, Senior Investigator Office of Inspector General

Licensing Division Enclosure

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


state: MN

facility_name: 180 Degrees St Cloud

raw_content:
May 30, 2025

Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud

236 Clifton Avenue

Minneapolis, MN 55403-3466 License Number: 1106751 (CRF)

CORRECTION ORDER

Dear Daniel Pfarr:

On April 22, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, 180 Degrees St. Cloud, located at  . This review was

conducted to determine compliance with state and federal laws and rules governing the provision of shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). 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.

PRACTICES

1. Violation: Three of four grievances reviewed did not meet requirements. Two grievances dated February 6, 2025 and one grievance dated February 24, 2025 did not document if the grievance was able to carried forward to the highest level of administration of the facility.

Statute/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 that grievance procedures meets all applicable requirements.

RESIDENT FILES

2. Violation: One of three resident files reviewed for requirements governing shelter admissions did not meet requirements (resident file numbered 1). There was no documentation to show that the health screening had been arranged within 24 hours of admitting a resident to shelter services.

Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that shelter admission procedures meets all applicable requirements.

3. Violation: One of two resident files reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 1). There was no documentation to demonstrate that the residents personal property was returned to the resident upon discharge.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13 and Minnesota Rules, part 2960.0090, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meet 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.

Submissions required as part of a corrective action ordered must be sent to DHS Licensing at:

1. By secure email to: maddy.moore@state.mn.us; or

2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Moore

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:

Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155

Questions

If you have any further questions regarding this matter, you may contact Maddy Moore, Senior Licensor, at 651-431-4585.

Sincerely,

Maddy Moore, Senior Licensor Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Correction Order


report_date: November 25, 2024

raw_content:
November 25, 2024

Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud

236 Clifton Avenue

Minneapolis, MN 55403-3466 License Number: 1106751 (CRF)

CORRECTION ORDER

Dear Daniel Pfarr:

On September 5, 2024, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at  .

As a result of this visit, DHS determined that you are in violation of 6 of the shelter care services requirements under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). 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.

PERSONNEL

1. Violation: One personnel file reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 2). The following trainings were not completed annually for 2024:

a. Vulnerable adults maltreatment reporting requirements;

b. The license holders program abuse prevention plan

c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services;

d. Maltreatment of minors reporting requirements;

e. Concepts of trauma informed care and how to provide services according to these concepts;

f. Impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma; and

g. Human trafficking training.

Statute/Rule Violated: Minnesota Statues, section 245A.25, subdivision 3, paragraph (h) and subdivision 5, paragraph (f) and 245A.65, subdivision 3 and 245A.66, subdivision 4 and Minnesota Rules part 2960.0100, subpart 3, items A and B and subpart 5 and 2960.0150, subpart 4, items B and D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation for personnel file numbered 2 that demonstrates compliance.

2. Violation: One personnel file reviewed for requirements governing training did not meet requirements (personnel file numbered 2). There was no documentation that the emergency plan was reviewed with staff at least every six months for the calendar year 2024.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 14.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance.

RESIDENT FILES

3. Violation: Two of two resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1 and 2). The inventory and handling of resident property upon admission did not include a date the form was completed. DHS licensing was unable to determine if it was completed upon admission.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating compliance.

4. Violation: One resident file reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements (resident file numbered 3). There was no documentation to demonstrate that the resident was involved in the creation of the IAPP.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual abuse prevention plans meet all applicable requirements.

5. Violation: One resident file reviewed for requirements governing health care services did not meet requirements (resident file numberd 1). There was no documentation to demonstrate that the license holder contacted the residents prescriber to verify the following information regarding prescribed medication:

a. Instructions about how the medication must be administered;

b. The symptoms the medication will alleviate; and

c. The symptoms that would warrant consultation with the 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 that health care services meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating compliance.

6. Violation: One resident file reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 2). The license holder did not provide the resident with a signed receipt of their personal property inventory upon discharge.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated February 21, 2024.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures 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.

Submissions required as part of a corrective action ordered must be sent to DHS Licensing at:

1. By secure email to: madelyn.gilbertson@state.mn.us; or

2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Gilbertson

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:

Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155

Questions

If you have any further questions regarding this matter, you may contact Maddy Gilbertson, Senior Licensor, at 651-431-4585.

Sincerely,

Maddy Gilbertson, Senior Licensor Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


report_date: February 21, 2024

raw_content:
February 21, 2024

Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud

236 Clifton Avenue

Minneapolis, MN 55403-3466 License Number: 1106751 (CRF)

CORRECTION ORDER

Dear Daniel Pfarr:

On December 11, 2023, a Department of Human Services (DHS) licensor conducted a modified licensing review at your facility located at  .

As a result of this visit, DHS determined that you are in violation of 10 of the shelter care services requirements under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). 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.

PRACTICES

1. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A.

Violation: The license holder failed to provide a medically licensed person to provide consultation and review of the license holder’s administration of medication on a monthly basis. At the time of the licensing review, the license holder had not maintained a medically licensed person on their staff since September 4, 2023.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must document their attempts to hire a medically licensed person. In the future, the license holder will be responsible for notifying the DHS licensor if they fail to employ a medically licensed person.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

2. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A.

Violation: The license holder failed to submit critical incident reports to DHS Licensing within ten days. Two of nine incident reports reviewed from June 2023, through September 2023, met the definition of a critical incident but were not reported (August 5 and 9, 2023).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that critical incident reporting meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

PERSONNEL FILES

3. Citation: Minnesota Rules, part 2960.0080, subpart 14.

Violation: One personnel file reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 1). The staff person did not receive ongoing training, every six months, on the license holder’s emergency plan.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance.

RESIDENT FILES

4. Citation: Minnesota Rules, part 2960.0070. subpart 3, item B.

Violation: One of two resident files reviewed for requirements governing resident information did not meet requirements (resident file numbered 1). The license holder failed to document the placing agency’s case plan goals for the resident.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client information meets all application requirements.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

5. Citation: Minnesota Rules, part 2960.0070, subpart 4.

Violation: Two of two resident files reviewed for requirements governing admission procedures did not meet requirements. The license holder failed to document the inventory and handing of resident property upon admission in the following ways:

a. Documentation of inventory and handling of resident property was completed late and was not signed by the resident. The document was signed by one staff person and is required to be signed by two, if the resident refuses to sign (resident file numbered 1); and

b. The inventory and handling of resident property form was started, but never completed, including signatures from staff and the resident (resident file numbered 2).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding the inventory and handling of resident property meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

6. Citation: Minnesota Rules, part 2960.0520, subpart 2, items A and B.

Violation: Two of two resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways (resident files numbered 1 and 2):

a. The license holder failed to document whether a health screening was arranged for within 24 hours of admittance to the program (resident file numbered 2); and

b. The license holder failed to assess the resident’s vulnerability to maltreatment and develop a plan to reduce the resident’s risk of maltreatment while in shelter (resident files numbered 1 and 2).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding shelter admissions meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

7. Citation: Minnesota Rules, part 2960.0080, subpart 11, item E.

Violation: One resident file reviewed for requirements governing health care services did not meet requirements (resident file numbered 2). The license holder failed to record the quantity of medication received from the pharmacy for a resident who receives prescription drugs at the facility.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding health care services meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance.

8. Citation: Minnesota Rules, part 2960.0530, subparts 1 and 2.

Violation: Four of four resident files reviewed for requirements governing limitations on length of stay in a shelter did not meet requirements in the following ways:

a. The license holder failed to apply for a variance to retain a resident in shelter beyond 90 days (resident files numbered 1, 3, and 4); and

b. The license holder did not complete a 30-day review after a resident remained in the shelter for more than 30 days. The review was completed late, after the resident had surpassed 30 days.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding limitations on length of stay in a shelter meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

9. Citation: Minnesota Rules, part 2960.0090, subpart 3.

Violation: One resident file reviewed for requirements governing the handling of resident’s personal property upon discharge did not meet requirements (resident file numbered 2). The license holder failed to obtain a date or signature on the document that logged the inventory of the resident’s personal property upon discharge.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding the handling of resident’s personal property upon discharge meets all applicable requirements.

10. Citation: Minnesota Rules, part 2960.0190, Subpart 1, items A and B and 2960.0520, subpart 2, item C.

Violation: Two of two resident files reviewed for requirements governing transition services plans did not meet requirements in the following ways:

a. The plan did not consider the environment that the resident would return to and recommend how the resident may deal with issues and potential challenges within that environment (resident files numbered 1 and 2); and

b. The plan did not demonstrate that it was developed with input from the resident’s family members, the providing school district, and the persons who will provide support services to the resident upon release (resident files numbered 1 and 2); and

c. Documentation did not demonstrate that a copy of the plan was given to the resident and to the school, or to the residential treatment facility that the resident will attend or is placed in after release (resident file numbered 2); and

d. The transition services plan did not include the following required components:

i. Housing, recreation, and leisure arrangements (resident file numbered 2); and

ii. Appropriate educational, vocational, rehabilitation or training services (resident files numbered 1 and 2); and

iii. A budget plan and description of the resident’s financial and employment status (resident files numbered 1 and 2); and

iv. Transportation (resident files numbered 1 and 2); and

v. Health services (resident files numbered 1 and 2); and

vi. Personal safety needs (resident files numbered 1 and 2).

e. The name and address of the party the resident was released to following discharge (resident file numbered 2).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation regarding transition services plans meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional License dated February 24, 2023.

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.

Submissions required as part of a corrective action ordered must be sent to DHS Licensing at:

1. By secure email to: madelyn.gilbertson@state.mn.us; or

2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Gilbertson

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:

Commissioner, Department of Human Services 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 Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155

Questions

If you have any further questions regarding this matter, you may contact Maddy Gilbertson, Senior Licensor, at 651-431-4585.

Sincerely,

Maddy Gilbertson, Senior Licensor Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


report_date: February 24, 2023

raw_content:
PUBLIC

Summary of Settlement Agreement

License Holder: 180 Degrees St. Cloud

License Number: 1106751

Program Type: Children’s Residential Facility (CRF)

Date of Licensing Action: February 24, 2023

Licensing Action Taken: Order of Conditional License

Reconsideration requested and settlement agreement signed by Commissioner on:

June 16, 2023

Terms of Settlement Agreement:

Conditional license not imposed; license holder operating pursuant to terms of settlement agreement.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Order


raw_content:
February 24, 2023

Daniel Pfarr, Authorized Agent 180 Degrees St. Cloud

236 Clifton Avenue

Minneapolis, MN 55403-3466 License Number: 1106751 (CRF)

ORDER OF CONDITIONAL LICENSE

Dear Daniel Pfarr:

The Department of Humans Services (DHS) is placing your license to provide children’s residential facilities group residential services (CRF) at  , on conditional status for

two years, beginning March 7, 2023. This order is based on your noncompliance with Children’s Residential Facility (CRF) licensing requirements. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

On December 12 through 16 and 19, 2022, DHS licensors conducted a licensing review at your facility located at

. As a result of this licensing review, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF), citing 21 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of children served by the program.

Nature and Severity:

· The license holder failed to provide oversight by a medically licensed person (citation numbered 1);

· The license holder failed to meet requirements governing health care services (citation numbered 2);

· The license holder failed to comply with background study requirements (citation numbered 3 through 5);

· The license holder failed to provide a physical environment that provided for the comfort, privacy and dignity of residents (citation numbered 6);

· The license holder failed to submit critical incident reports to DHS licensing within ten days (citation numbered 7)

· The license holder failed to meet requirements governing the limitations of length of stay in programs providing shelter care services (citation numbered 8);

· The license holder failed to monitor implementation of their grievance policy (citation numbered 9);

· The license holder failed to provide complete orientation training to staff (citation numbered 10);

· The license holder failed to provide ongoing staff training (citation numbered 11);

Due to the nature and severity of these violations that impact the health and safety of children served in your care, your license to provide Children’s Residential Facility services is placed on a conditional status.

Licensing Violations

DHS determined that your program failed to follow licensing rules and statutes, as described below.

1. Violation: The license holder failed to provide a medically licensed person to provide consultation and review of the license holder’s administration of medication on a monthly basis. At the time of the licensing review, the license holder had not maintained a medically licensed person on their staff since November 15, 2021.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A.

2. Violation: Four of four resident files reviewed for requirements governing health care services did not meet requirements in the following ways:

a. The license holder failed to maintain a record of the resident’s medical, psychological, or dental care (resident files numbered 1 through 4);

b. The license holder failed to contact a newly admitted resident's prescribing medically licensed person to verify the following information regarding prescribed medication (resident files numbered 1, 2, and 4):

i. Instructions about how the medication must be administered;

ii. The symptoms that the medication will alleviate;

iii. The symptoms that would warrant consultation with the physician;

c. Documentation did not identify the prescribing physician’s directions for monitoring medications used by the resident (resident files numbered 1 through 4); and

d. The resident file did not include the following required medication documentation (resident file numbered 4):

i. The quantity of medication initially received from the pharmacy; and

ii. The amount of medication given, the dosage, and the time when the medication was taken.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items B, D and E

3. Violation: The license holder failed to meet background study (BGS) requirements for four staff. (personnel numbered 5 through 8). The license holder failed to initiate a BGS before an adult, regardless of whether or not the individual will have direct contact with persons served by the facility,

begins working in the facility or setting. In addition, the license holder did not prohibit activities of working in the facility prior to receipt of notice of the BGS results.

a. Staff person (personnel file numbered 5) began working in the facility August 20, 2022; however, the license holder did not have a BGS notice result until December 8, 2022;

b. Staff person (personnel file numbered 6), was hired on July 1, 2021. License holder did not document the date of working in the facility as required; however, the license holder did not have a BGS notice result until December 8, 2022;

c. Staff person (personnel file numbered 7) began working in the facility May 20, 2022; however, the license holder did not have a BGS notice result until December 8, 2022; and

d. Staff person (personnel file numbered 8) began working in the facility August 19, 2021; however, the license holder did not have a BGS notice result until December 8, 2022.

Statute Violated: Minnesota Statutes, section 245A.041, subdivision 5, 245C.04, subdivision 11, clause

(5) and 245C.13, subdivision 2, paragraph (c).

4. Violation: The license holder failed to transfer a BGS from a closed license to an active license. On December 12, 2022, a DHS Licensor determined that the license holder did not notify the Commissioner to transfer background studies to an active license when license number 1062155 closed. Staff person (personnel file numbered 2) had BGS completed under Department of Corrections, license number 1062155. When the licensed closed on June 1, 2021, the license holder did not notify the Commissioner to transfer the BGS to an active licensed under 245C.

Statute Violated: Minnesota Statutes, section 245C.07, paragraph (b).

5. Violation: The license holder has multiple programs but failed to affiliate a staff person (personnel file numbered 4) on all active rosters. A BGS was submitted under license number 1074484; however, staff person was also working under license number 1106751 as of July 11, 2022.

Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f).

6. Violation: The license holder failed to ensure the physical environment provided for the comfort, privacy and dignity of residents. During the on-site licensing review, a DHS Licensor observed bedroom walls with vulgar graffiti, torn carpet, and evidence of water damage. Staff on site indicated that the programs usual practice of adequately maintaining the environment was not being followed due to the ongoing remodeling project.

Rule Violated: Minnesota Rules, part 2960.0110, subparts 2 and 3, item A.

7. Violation: The license holder failed to submit critical incident reports to DHS Licensing within ten days. Five of ten incident reports reviewed from October 2022, through December 2022, met the definition of a critical incident but were not reported (November 4, 11, 15, 16 and 25, 2022).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A.

8. Violation: The license holder failed to meet requirements governing the limitations of length of stay in programs providing shelter care services in the follow ways:

a. The license holder retained residents for longer than 90 days without requesting a variance as directed by Minnesota Rules, part 2960.0530, subpart 1. During the review period of July 1, 2021, through December 15, 2022, nine residents remained in shelter beyond the 90 day limit; and

b. Two of two resident files reviewed for requirements governing 30-day reviews did not meet requirement. There was no documentation to demonstrate the license holder reviewed the need for the resident to remain in shelter and consider alternative placement plans when the resident was in shelter for more than 30 days (resident files numbered 2 and 4).

Rule Violated: Minnesota Rules, part 2960.0530, subparts 1 and 2.

9. Violation: Eleven of twelve grievances reviewed did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the person who submitted the grievance received a response (grievances dated December 25, 2021, February 26, 2022, March 13, 16, 26,

and 29 (2) 2022, August 17, 2022, September 10, 2022, and two undated grievances); and

b. The person that submitted the grievance did not receive a response within five days. Grievances dated July 30, 2022, and August 17, 2022, were responded to late.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, items A and B.

10. Violation: Two of two personnel files reviewed for requirements governing orientation did not meet requirements in the following ways:

a. There was no documentation to demonstrate the staff person was trained on the following topics prior to having unsupervised contact with residents (personnel files numbered 1 and 3):

i. Emergency procedures;

ii. Maltreatment of minors reporting requirements;

iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents;

iv. General and special needs, including disability needs, of residents and families served;

v. Operational policies and procedures of the license holder, including the program’s drug and alcohol policy; and

vi. Data practices regulations and issues.

b. There was no documentation to demonstrate the staff person was trained on the following topics within 72 hours of first providing direct contact services to vulnerable adults (personnel files numbered 1 and 3):

i. Vulnerable adults maltreatment reporting requirements and definitions;

ii. The license holder’s program abuse prevention plan (PAPP); and

iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and

c. Documentation of orientation did not include the date, number of hours, or the name of the entity that provided the training (personnel file numbered 1).

Rule and Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, part C, 245A.65 subdivision 3, and Minnesota Rules, part 2960.0100, subpart 3, item A.

11. Violation: One personnel file reviewed for requirements governing ongoing training did not meet requirements in the following ways (personnel file numbered 2):

a. The staff person did not receive annual training in 2021 to the following required topics:

i. Vulnerable adult maltreatment and reporting requirements and definitions;

ii. The license holders PAPP;

iii. The license holders emergency plan; and

b. Documentation of in-service training did not include the date and number of hours of training completed by each staff person in each topic area and the name of the entity that provided the training.

Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subparts 3, item B, and 5.

12. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements in the following ways:

a. The resident file did not contain the placing agency’s case plan, and there was no documentation of the license holder’s efforts to obtain the case plan (resident files numbered 1 through 3);

b. There was no documentation of the inventory and handling of resident property (resident file numbered 1);

c. Documentation indicated the license holder did not communicate the facility rules and due process system to the resident (resident files numbered 1 through 3); and

d. Documentation indicated the license holder did not provide a copy of the resident rights to the resident (resident files numbered 1 through 3).

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 3, items A and B, and 2960.0070, subparts 3, item B, and 4, and 2960.0080, subpart 4.

13. Violation: One resident file reviewed for requirements governing the provision of services to vulnerable adults did not meet requirements in the follow ways (resident file numbered 4):

a. An individual abuse prevention plan was not developed;

b. The resident was not oriented to internal and external reporting policies; and

c. The resident was not oriented to the program abuse prevention plan.

Statute Violated: Minnesota Statute, section 245A.65, subdivision 1, paragraph (c).

14. Violation: Four of four resident files reviewed for requirements governing shelter admissions did not meet requirements in the following ways:

a. There was no documentation to demonstrate that a health screening was arranged within 24 hours of being admitted to the program (resident files numbered 1 through 4);

b. The license holder failed to assess the residents vulnerability to maltreatment and to develop a plan to reduce the residents risk of maltreatment while in the shelter (resident files numbered 1 through 4);

c. The license holder failed to specify short-term objectives and methods for meeting the immediate needs identified (resident files numbered 1 through 4);

d. Documentation did not indicate the license holder’s responsibility for meeting the residents needs as identified by the placing agency (resident files numbered 1 and 3); and

e. The license holder failed to document, within six working days of admission, the degree to which the family desires to be involved during the residents stay at the facility (resident files numbered 2 and 3).

Rule Violated: Minnesota Rules, parts 2960.0070, subpart 5, item D; and 2960.0080, subpart 19; 2960.0520, subparts 2, items A and B, and 3, items B and C.

15. Violation: Three of three resident files reviewed for requirements governing program services did not meet requirements in the following ways:

a. There was no documentation provided that demonstrated that the license holder worked with the resident, parent, or legal representative, and the resident's case manager and treatment team to implement the resident's case plan during the resident's stay in the facility (resident files numbered 1 and 2); and

b. The license holder failed to identify and share information about the resident’s treatment and major treatment outcomes (resident files numbered 1 and 3).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 3, items A and B.

16. Violation: Three of three resident files reviewed for requirements governing discharge documentation did not meet requirements in the following ways:

a. The license holder failed to document the extent to which the residents stay in the facility met the goals and objectives of the residents treatment plan (resident files numbered 1 and 4);

b. The resident file did not contain a transition services plan, when the resident remained in shelter for more than 10 days (resident files numbered 1, 3 and 4); and

c. Documentation did not identify the name and address of the party the resident was released to following discharge (resident file numbered 4).

Rule Violated: Minnesota Rules, parts 2960.0190, subparts 1 and 2; and 2960.0520, subpart 2, item C.

17. Violation: The license holder’s plan for the transfer of client records upon closure did not meet requirements. There was no documentation to demonstrate the plan was reviewed by a controlling individual annually, for 2021 and 2022.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a).

18. Violation: The license holder’s operational policies and procedures did not meet requirements in the following ways:

a. The license holder failed to maintain a written schedule of daily activities that generally describes the residents activities for each day of the week; and

b. The license holder failed to develop and implement a plan that offers appropriate recreation for residents

Rule Violated: Minnesota Rules, part 2960.0080, subparts 6 and 10.

19. Violation: The license holder’s postings did not meet requirements. The rights posted in an area readily seen by residents and staff were incorrect and not applicable, and the resident’s rights were not posted in the staff workstation. During the on-site licensing review, the license holder posted the correct rights in all required areas.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, items C and D.

20. Violation: The license holder’s review of the program abuse prevention plan (PAPP) did not meet requirements. There was no documentation to demonstrate that the license holder’s governing body reviewed the PAPP annually, for 2021 and 2022.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph item (a).

21. Violation: The license holder’s program evaluation did not meet requirements. The license holder failed to evaluate strengths and weaknesses of the program on an annual basis and use the results of the evaluation to make improvements in its program for 2021 and 2022.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A.

Immediate corrective action required

You must immediately correct the violations cited above. Submit documentation to your licensor within 45 days from when you received this order explaining how you have corrected the violations.

1. By secure email to: madelyn.gilbertson@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services ATTN: Madelyn Gilbertson

Licensing Division PO Box 64242

St. Paul, MN 55164-0242

If you fail to demonstrate substantial compliance with licensed children’s group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license.

CONDITIONAL LICENSE TERMS

In addition to the licensing rules and statutes, you are required to comply with the following terms:

1. Within 14 days of receipt of this order, you must notify current residents and all parties who refer residents to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request.

While the license is on conditional status, you must notify new residents and referral sources the license is on conditional status before they begin receiving treatment services. The notification to new residents must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file.

Within 30 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice.

2. Within 30 days of receipt of this order, you must develop a self-monitoring tool and plan that ensures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following:

a. Names and titles of those responsible to carry out duties within the plan; and

b. Procedure that includes a sample review of resident records, personnel files, treatment plans and reviews, transition and discharge plans, medication administration records and medication verifications, incident reports, grievances, and monitoring of the implementation of policies and procedures on a monthly basis.

c. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on April 15, 2023, July 15, 2023, October 15, 2023, and January 15,

2024, April 15, 2024, July 15, 2024, October, 15, 2024, January 15, 2025 or until otherwise determined by DHS Licensing.

3. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on statute requirements for Background Studies under Minnesota Statute, chapter 245C. Individuals required to attend is your designated N2study sensitive information person and authorized agent. Training must be completed within 30 days of receipt of this order.

4. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on rule requirements for children's residential facilities Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. Individuals required to attend are the Program Manager, Registered Nurse, Compliance Officer, Director and Partner Experience must attend the training offered by DHS Licensing. Training must be completed within 60 days of receipt of this order.

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

· Clearly state that you are requesting reconsideration of the conditional license

· List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· State why you believe your license should not be on a conditional status

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 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:

Commissioner, Department of Human Services 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 10 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 Attn: Licensing Legal Unit 444 Lafayette Road North

St. Paul, MN 55155

Conditional license stayed pending reconsideration

If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530 laws and rules.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· Children’s residential facilities are required to follow Minnesota Rules, 2960.0010 through 2960.0220 and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4.

· If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4.

· Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order.

Questions

If you have any further questions regarding this matter, you may contact Katie Leuer, Supervisor, at 651-431-6259.

Sincerely,

Paula Halverson, Unit Manager Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


raw_content:
October 1st, 2024

Samantha Sorensen, Authorized Agent

Fairview Health Services

1675 Beam Ave.

Maplewood, MN 55109

License Number: 830715

CORRECTION ORDER

Dear Samantha Sorensen,

On August 12 and 13 of 2024 the Department of Human Services (DHS) conducted a licensing review at your facility, Adolescent Residential Substance Abuse Program, located at 1675 Beam Ave, Maplewood, Minnesota 55109. 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, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and chemical dependency treatment program certification standards under Minnesota Rules, parts 2960.0430 through 2960.04900. As a result of this visit, 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 VIOLATION

DHS determined that your program failed to follow licensing rules and statutes, as described below.

Policies and Practices

1. Violation: The license holder did not meet requirements governing community involvement. There was no documentation to demonstrate the license holder met annually with community leaders represented in the area.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 6

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure outcome measures meet all applicable requirements.

Resident Files

2. Violation: One of three resident files reviewed for requirements governing admission criteria did not requirements (resident file numbered 2). The license holder did not determine and document whether:

a. The program could meet the resident’s needs;

b. The resident was a danger to themselves or others; and

c. The program is able to meet the resident’s cultural, emotional, educational, mental health and physical needs.

Rule Violated: Minnesota Rules, part 2960.0160, subpart 2, items A and C

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission determinations meet all applicable requirements.

3. Violation: Two of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1 and 2). There was no documentation to demonstrate the license holder inventoried the resident’s personal property.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission procedures meet all applicable requirements.

4. Violation: Two of three resident files reviewed for requirements governing admission screenings did not meet requirements (resident files numbered 1 and 2). There was no documentation to demonstrate the license holder determined the degree to which the resident’s family desired to be involved in the resident’s stay.

Rule Violated: Minnesota rules, part 2960.0070, subpart 5, item D

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission screenings meet all applicable requirements.

5. Violation: Three of three residents files reviewed for requirements governing treatment plans did not meet requirements in the following ways:

a. The license holder did not assign a designated staff person to ensure regular face-to-face contact and to monitor and assist the resident to implement the treatment plan (resident files numbered 1, 2, and 3);

b. The license holder did not document the participation of others in the plan (resident file numbered 2); and

c. The treatment plan did not include specific intervals at which resident progress must be reviewed (resident files numbered 1, 2, and 3).

Rule Violated: Minnesota rules, parts 2960.0180, subpart 2, item B, and 2960.0490, subparts 2 and 3, item D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure treatment plans meet all applicable requirements. Within 30 days receipt of this order, submit a treatment plan that demonstrates compliance.

6. Violation: One of three resident files reviewed for requirements governing individual treatment plan reviews did not meet requirements (resident file numbered 1). The individual treatment plan was not reviewed every two weeks for weeks beginning 3/21/2024, 4/5/2024, and 4/23/2024.

Rule Violated: Minnesota rule, part 2960.0490, subpart 5

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service plan review meet all applicable requirements.

7. Violation: Three of four resident files reviewed for requirements governing health care did not meet requirements in the following ways:

a. The license holder’s documentation did not show attempts to contact the child’s parent or guardian to seek permission for the facility to administer prescription (resident files numbered 1 and 4); and

b. There was no documentation to show that the license holder gave the resident’s parent or legal guardian their prescription medication upon release, or disposed of the medication according to a pharmacy-approved plan (resident files numbered 2 and 4).

Rule Violated: Minnesota rules, part 2960.0080, subpart 11, items D and F

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure provision and documentation of health care meet all applicable requirements.

8. Violation: Two of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident files numbered 1 and 2). There was no documentation to demonstrate that the personal property of a resident was returned.

Rule Violated: Minnesota rules, part 2960.0090, subpart 3

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of discharge procedures meet all applicable requirements.

9. Violation: Three of three resident files reviewed for requirements governing transition services plan did not meet requirements (resident files numbered 1, 2, and 3). The plan did not consider the environment into which the resident will return, nor recommend how the resident may deal with issues and potential challenges within the environment.

Rule Violated: Minnesota rules, part 2960.0190, subpart 1, item A

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure provision and documentation of transition services plans meet all applicable requirements. Within 30 days receipt of this order, submit a transition services plan that demonstrates compliance.

Personnel Files

10. Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements (personnel files numbered 1, 2, 3, and 5). The license holder did not review the emergency plan with staff at least once every six months.

Rule Violated: Minnesota rule, part 2960.0080, subpart 14

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure provision and documentation of ongoing training meet 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 (hannah.horsch@state.mn.us) or mail:

Commissioner, Department of Human Services

ATTN: Hannah Horsch

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:

Commissioner, Department of Human Services

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

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960.

· 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 651-431-6259.

Sincerely,

Katie Leuer, Unit Supervisor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


facility_name: Ain Dah Yung (our Home) Center

raw_content:
July 31, 2025

Sheri Reimers, Authorized Agent Ain Dah Yung Center

License Number: 800051 (CRF)

CORRECTION ORDER

Dear Sheri Reimers:

On May 13 and 14, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Ain Dah Yung Center, located at  . 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 shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530.

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, Procedures and Practices

1. Violation: The license holder's policy on reporting maltreatment of minors did not meet requirements. The policy did not reference chapter 260E, it referenced a repealed statute that is no longer applicable.

Statute Violated: Minnesota Statute, section 245A.66

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the Maltreatment of Minors reporting policy meets requirements.

2. Violation: The license holder’s policy on emergency plans did not meet requirements. The plan did not include a response to a natural disaster.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 14.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure emergency plans meet requirements.

3. Violation: The license holder’s plan for the transfer of clients and records did not meet requirements. An annual review of the plan was not completed in 2024.

Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the ongoing review of the plan for transfer meets requirements.

4. Violation: The license holder’s program evaluation did not meet requirements. There was no documentation to demonstrate an annual evaluation of the program’s strengths and weaknesses was completed for calendar years 2023 and 2024.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 3, item A.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure outcome measures meet requirements. Within 30 days receipt of this order, submit documentation demonstrating how an annual evaluation will be completed.

Personnel Files

5. Violation: Two of two personnel files reviewed for orientation training did not meet requirements (personnel files numbered 1 and 5). There was no documentation to demonstrate orientation to the following required topics was provided prior to direct contact services:

a. Emergency procedures;

b. Maltreatment of Minors reporting requirements;

c. Cultural diversity and gender sensitivity, culturally specific services and information about discrimination and racial bias issues;

d. General and special needs, including disability needs of residents and families served;

e. Operational policies and procedures of the license holder;

f. Data practices regulations and issues; and

g. There was no documentation to demonstrate the staff person received training on administering admission screenings.

Rule Violated: Minnesota Rules, parts 2960.0100, subpart 3, item A; and 2960.0070, subpart 5.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel files numbered 1 and 5 to demonstrate compliance.

6. Violation: Three of three personnel files reviewed for ongoing training did not meet requirements (personnel files numbered 2, 3 and 4). There was no documentation to demonstrate the staff person received ongoing training for calendar years 2023 and 2024 on the following required topics:

a. Training that is modified annually to meet the current needs of individual staff persons and is directly related to serving the programs target population and achieving program outcomes;

b. Training on program policies and procedures necessary to maintain compliance with licensing requirements;

c. Training that helps staff meet the needs of residents, and includes skill development;

d. Maltreatment of minors reporting requirements;

e. Review of the emergency plans every six months; and

f. The date, name of trainer, topic of training and length of training.

Statute and Rule Violated: Minnesota Statute, sections 245A.04, subdivision 14, paragraph (b); 245A.66, subdivision 4; and Minnesota Rules, parts 2960.0100, subparts 3, item B, and 5; and 2960.0080, subpart 14.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel files numbered 2, 3 and 4 to demonstrate compliance.

Resident Files

7. Violation: One of three resident files reviewed for resident admission documentation did not meet requirements. The resident file did not include the placing agency’s case plan goals for the resident, and there was no documentation demonstrating the license holder attempted to obtain a copy of the plan (resident file numbered 1).

Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that resident admission information meets all applicable requirements.

8. Violation: Two of three resident files reviewed for admission procedures did not meet requirements in the following ways:

a. An assessment of the resident’s vulnerability to maltreatment, and a plan to reduce the risk of maltreatment while in shelter, was not completed (resident file numbered 2);

b. The license holder did not inventory the resident’s personal property upon admission (resident file numbered 2); and

c. The license holder provided a copy of resident’s basic rights that included inaccurate information. The copy of the rights included information on the license holder’s grievance procedure, which stated that the person could contact outside government entities if the grievance was not resolved (resident file numbered 1).

Rule Violated: Minnesota Rules, parts 2960.0520, subpart 2, item A; and 2960.0050, subpart 3, item A and 2960.0070, subpart 4.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements.

9. Violation: Three of four files reviewed for requirements governing health care did not meet requirements in the following ways:

a. The license holder did not ensure the resident’s right to adequate medical care was protected (resident file numbered 1). Admission documentation dated July 29, 2024, identified the need for dental and eye examinations. A case note dated October 21, 2024, indicated the resident requested appointments for these examinations. A case note identified that the resident complained of dental pain and attended an emergency dental appointment on February 18, 2025 (resident file numbered 1);

b. Documentation did not identify the initial quantity of medication received from the pharmacy (resident files numbered 1, 2 and 3); and

c. The medication administration record did not document the amount of medication given, the dosage, and time when the medication was taken (resident file numbered 1).

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 1, item F, 2960.0080, subpart 11, item E.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care meets all applicable requirements.

10. Violation: Two of two resident files (resident files numbered 1and 4) reviewed for no eject did not meet requirements in the following ways:

a. The license holder did not document conferring with interested persons to review issues involved in the decision to discharge;

b. The license holder did not document whether they, together with other interested persons, attempted to develop additional strategies to resolve the issues leading to discharge within a five-day period;

c. The license holder did not document if the discharge was warranted, the reasons for it and the alternatives considered or attempted.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

Repeat Violation: In a Correction Order that DHS issued on February 9, 2023, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that no eject meets all applicable requirements. Within 30 days receipt of this order, submit documentation of a no-eject discharge to demonstrate compliance.

11. Violation: One resident file (resident file numbered 1) reviewed did not meet requirements governing the license holder’s compliance with an approved variance extending the length of stay in a shelter. There was no documentation to demonstrate the license holder complied with a condition of the variance approval dated 10/30/2024 to provide at least 10 hours of services per week.

Rule Violated: Minnesota Statute, section 245A.04, subdivision 9.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must follow all terms of approved variance requests.

12. Violation: Two of two resident files reviewed for discharge procedures did not meet requirements. The license holder did not document return of the resident’s belongings with a signed receipt (resident files numbered 1 and 4).

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meets all applicable requirements.

13. Violation: Two of two resident files reviewed for transition services plan did not meet requirements in the following ways:

a. The license holder did not document input from the resident’s family members, school or support services (resident file numbered 2);

b. The license holder did not document providing a copy of the transition plan to family members, school or support services (resident files numbered 1 and 2).

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plan 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 Laura.Huff1@state.mn.us or by mail:

Commissioner, Department of Human Services ATTN: Laura Huff

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 651-431-4234 or at Laura.Huff1@state.mn.us

Sincerely,

Laura Huff, Licensor Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/