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MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”

Report Number: 202210368

Date Issued: March 29, 2023

Name and Address of Facility Investigated:

Hennepin County Juvenile Detention Center
510 Park Avenue South
Minneapolis, MN 55415

Disposition: Maltreatment determined as to neglect of an alleged victim by three staff persons.

License Number and Program Type:

1036881-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
beth.virden@state.mn.us

651-431-6572

Suspected Maltreatment Reported:

It was reported that an alleged victim (AV) was found unresponsive, on the floor, in his/her bedroom. Staff persons waited approximately 20 minutes before checking on the AV and at that point, discovered something tied around his/her neck. The item was untied and additional care was sought at that point. The AV was unharmed.

Date of Incident(s): November 4, 2022

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2):

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on December 29, 2022; from documentation and camera footage at the facility; and through interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1-SP3), a staff person (P1) who was a facility nurse, and a supervisory staff person (P2).

According to the facility’s website, www.hennepin.us, “The Hennepin County Juvenile Detention Center is a secure 24-hour pre-adjudication facility housing 10- to 17-year-olds while their cases are assessed by the court … The facility has a capacity of 87 beds with a nine-day average length of stay.”

The facility had more than one unit to house the residents. There were staff assigned to each unit, who were also able to respond to other units if additional staff were needed. The AV’s unit was multi-level with the communal areas being on the middle floor, including dining room and staff office; and then stairs going up and down to the bedroom areas. The AV’s bedroom, of which the AV was the sole occupant, was on the lower level. Each bedroom door had a window approximately 4 by 18 inches allowing visibility in and out of the room. The facility had cameras mounted in the communal areas, not inside bedrooms or bathrooms, which recorded activities, but not audio.

On November 1, 2022, the AV arrived at the facility pending court proceedings. The AV was 16 years old. The AV did not have a history of attempting to “hurt or kill” him/herself. The staff person, who completed the AV’s intake assessment, did not observe any signs the AV was suicidal and documented that the AV appeared “mentally stable, focused, responsive, and alert.”

The facility’s policies and procedures, including Visual Well-Being Checks and Medical Emergencies, stated the following:

· All staff persons were required to carry a two-way radio when working. There were various types of radio calls a staff person might use. A “back-up” radio call indicated the need for an immediate response to the stated location by all available staff; a “medical back-up” included a request for medical staff.

· Unit staff conducted well-being checks of every resident at irregular intervals not to exceed 30 minutes between checks. Staff conducted checks at more frequent intervals when they believed a resident’s well-being might be in question.

· Regarding how to conduct a well-being check:

o “When conducting well-being checks of residents in their rooms, staff will stop at each resident door/window and postion [sic] themselves to visually observe either the skin of, and/or movement by a resident in the room. In addition, staff will ensure the resident’s head is uncovered, check for respiration and/or movement and perform a quick check of the room to look for obvious damage or potential security and safety concerns.”

o If the resident cannot be seen through the window, a verbal command will be given telling the resident to make themselves visible. If the resident does not comply, it is necessary to obtain assistance and enter the room to complete the check.”

o Staff persons documented the well-being checks on the facility’s Well-Being Record.

· Any facility staff certified in first aid and/or cardiopulmonary resuscitation (CPR), who encountered an “injured person” within the facility, responded immediately by checking the scene safety; checking the person for responsiveness; checking the person’s airway, breathing, and circulation; and administering first aid as needed. The staff person then radioed a “medical back-up,” and/or whatever other resource was needed.

The AV told this investigator that at the time of the incident, s/he was upset about being restricted to his/her bedroom. The AV tied a sheet around his/her neck to “act like” s/he was “dead.” The AV then lay on the floor and waited for the staff to respond. However, over the next 20 to 30 minutes, staff checked on the AV three separate times, but “didn’t care at all” about the AV’s condition. In response, the AV “tied [the sheet] a little tighter,” which caused him/her to “pass out.” When the AV woke up, s/he saw P2 standing over him/her.

This investigator spoke with the FM over the phone. The facility previously told the FM about the incident, herein. The FM did not have anything to add about this specific incident, but said that s/he had concerns about previous incidents. The FM told this investigator that s/he was not in an appropriate spot to vocalize these concerns, but that s/he would email this information to this investigator on a later day. The FM did not reach out or email this investigator with additional information or concerns by the completion of this investigation.

SP1-SP3, P1, P2, and facility documentation and camera footage provided the following information:

· The facility’s Incident Reports stated that on November 1, 2022, the AV was involved in a physical altercation with another youth. This, resulted in the AV being placed on disciplinary room time (DRT) until November 4, 2022. [Note: Consistent information was provided that DRT meant the AV was restricted to his/her bedroom for most hours of the day.]

· The facility’s Staff Assignments stated that on November 4, 2022, SP1-SP3 were assigned to work on the AV’s unit. P1 and P2 were assigned to work in other areas of the facility.

· The AV’s DRT had expired allowing him/her to leave his/her bedroom. P1, P2, and SP1-SP3 were each not aware of indications or statements the AV was suicidal or contemplating self-harm on November 4, 2022.

· The facility’s Incident Reports stated that at 10:23 a.m., on November 4, 2022, the AV was out of his/her bedroom for an undisclosed reason. The AV started yelling and swearing at SP3. When SP3 prompted the AV to return to his/her bedroom, the AV declined and threw orange peels at SP3. SP3 radioed for a “back-up,” and the responding staff convinced the AV to go into his/her room. Around 10:26 a.m., the AV’s bedroom door was secured, and the AV was placed on “awaiting due process” (ADP) status, which, again, meant the AV was not allowed to leave his/her bedroom.

· SP1-SP3 each said that the AV was “upset” about being restricted to his/her bedroom. SP1 said that the AV was “pissed.” SP2 and SP3 each described how the AV repeatedly pounded on his/her bedroom door.

· The facility’s Well-Being Record stated that at 11:13 and 11:35 a.m., SP3 completed well-being checks of the residents, including the AV, who remained in his/her bedroom. SP3 did not document concerns for anyone’s well-being. [Note: The Well-Being Record did not document what each resident was doing at the time of a check.]

· The facility’s Well-Being Record stated that at 12 p.m., SP2 completed a well-being check of the residents. SP2 told this investigator that at the time of this check, the AV was lying on his/her bed and appeared unharmed.

· Also around 12 p.m., SP1 and SP2 prepared lunch trays in the dining room while all of the residents remained in their respective bedrooms with doors secured. Information was provided that at each meal, staff delivered prepared lunch trays to residents, who were restricted to their bedrooms for disciplinary reasons; and that once these trays were delivered, the remaining residents were allowed out of their rooms to eat in the dining room.

· The facility’s camera footage showed that at 12:04:25 p.m., SP1 walked down the stairs into the lower bedroom area towards the AV’s bedroom, carrying a prepared lunch tray. At 12:04:37 p.m., SP1 stood outside the AV’s bedroom looking into the room through the window. At 12:04:50 p.m., SP1 keyed open the AV’s bedroom door. SP1 stood in the door threshold and did not appear to be moving. At 12:05:24 p.m., SP1 backed out of the threshold, closed the door behind him/her, and then carried the same lunch tray back to the dining room.

· SP1 said that when s/he looked into the AV’s room, s/he saw the AV lying face-down on the floor with his/her head near the door and his/her feet going away from the door. SP1 called the AV’s name and asked if the AV wanted lunch but the AV did not respond or move. According to SP1, the AV’s face was towards the wall, not visible to SP1, and about four to five feet from the door. The AV’s arms were outstretched above his/her head. SP1 saw the AV’s chest rise and fall, which indicated to SP1 that the AV was breathing. SP1 did not see anything around the AV’s neck, and did not see “blood” or “weapons” in the room, or other cause for concern. SP1 said that if s/he had observed something tied around the AV’s neck, s/he would have radioed a “medical backup,” went into the room, and alleviated the pressure or restriction on the AV’s neck. [Note: At the time of the site visit, this investigator observed the AV with short head hair wearing facility-issued attire, which did not contain a hood. This investigator believed that if the AV’s hair length was the same or similar on November 4, 2022, it was unlikely the AV’s hair played a factor in SP1’s view of the AV’s neck. However, that said, this investigator did not know the AV’s hair length at the time of the incident and did not know if the AV was wearing something other than facility-issued attire without a hood.]

· SP1 explained that s/he had a history with the AV, and knew that when the AV was “upset,” s/he would sometimes “ignore” staff. For instance, the AV would lay on his/her bed and not respond to staff. SP1 had no experience of observing the AV lying on the floor.

· At the time of this incident, SP1 was aware that the AV had been placed on ADP and was “pissed” because of this. SP1 did not observe anything in the room or with the AV that led him/her to believe there was a medical emergency, or a need to radio a “backup.” SP1 believed that AV was intentionally ignoring him/her and was “playing opossum.” SP1 decided to leave and check on the AV at a later point.

· SP2 said that SP1 approached and told him/her, “[The AV] is laying on the floor. Just laying there.” SP1 asked that SP2 join him/her for a second well-being check of the AV. SP1 did not say anything about there being something tied around the AV’s neck.

· The facility’s camera footage showed that at 12:09:07 p.m., SP1 and SP2 walked down the stairs into the lower bedroom area arriving outside the AV’s bedroom door at 12:09:16 p.m. SP1 keyed the door open. SP1 and SP2 each stood outside the open door on either side of the doorframe and did not appear to be moving. At 12:09:38 p.m., SP1 and SP2 closed the door and walked back to the dining room.

· SP1 said that between his/her first check on the AV and now this second check with SP2, the AV’s arms had changed position. The AV was still lying in the same manner, but the positioning of his/her arms looked different to SP1.

· SP2 said that the AV was lying face-down on the floor with his/her head towards the door. SP2 could not see the AV’s face because it was towards the wall. SP2 saw the AV’s chest rise and fall, which indicated to SP2 that the AV was breathing. SP2 did not see any blood or anything tied around the AV’s neck. SP1 and SP2 repeatedly knocked on the door and yelled the AV’s name, but the AV did not move or respond.

· SP2 said that according to his/her training, if s/he came across an unresponsive person lying on the floor, s/he was supposed to call a medical back-up. Regarding this incident, SP2 did not call a medical back-up because the AV had been “active” and “wound up” earlier in the day and when SP2 checked on the AV at 12 p.m., the AV was lying on his/her bed, unharmed. Given that only a few minutes had passed since that, SP2 did not believe there was a need for immediate medical services. SP2 could see the AV breathing. SP2 was aware, based on the facility’s medical slips, the AV did not have a medical conditions that might cause an emergency situation. SP2 believed it was appropriate to continually check on the AV and prompt him/her to respond to them. SP2 did not believe the situation “add[ed] up” to a medical emergency.

· SP3 said that SP1 approached and told him/her that the AV was lying on the floor and not responding. SP3 believed SP1 also mentioned the AV having “something on [his/her] neck,” but SP3 was not positive if or when this was told to him/her.

· The facility’s camera footage showed that at 12:20:01 p.m., SP1 and SP3 walked down the stairs into the lower bedroom area towards the AV’s bedroom. SP1 arrived outside the room at 12:20:05 p.m., looked through the window and then stepped away to give space to SP3. SP3 looked through the window at 12:20:10 p.m. At 12:20:17 p.m., SP3 turned to leave and SP1 removed his/her two way radio from his/her belt and appeared to be speaking into it. SP1 and SP3 walked out of the bedroom area and returned to the dining room.

· SP3 said that upon arriving at the AV’s bedroom, SP3 saw the AV lying on the floor with a towel around his/her neck. SP3 told SP1 to radio a medical back-up “right away.” SP3 recalled that at some point prior to 12 p.m., the AV had been “bouncing” (pounding) on his/her bedroom door. The AV was “upset” with staff for being placed on room restriction. However, according to SP3, despite this, even if the AV was sleeping on the floor, they needed to radio a medical backup to ensure the AV was okay.

· SP1 said that the staff, who responded to the medical backup, discovered the item tied around the AV’s neck. SP1 did not see anything tied around the AV’s neck at any point when s/he checked on the AV; and SP2 and SP3 never told SP1 that they saw anything tied around the AV’s neck. SP1 believed that if SP2 and/or SP3 had seen something tied around the AV’s neck, they would have told SP1 right away. SP1 also believed that s/he, SP2, and SP3 would have taken immediate action if any of them saw something tied around a youth’s neck.

· SP1 believed that when the AV overheard the radio call for a medical backup, at that point the AV “decided to turn it up a notch” by tying something around his/her neck. [Note: SP1 and SP3 walked out of the bedroom area upon calling the medical backup and did not continue to watch the AV or see if the AV moved positions.]

· The facility’s camera footage showed that at 12:21:08 p.m., several additional staff persons, including P1 and P2, arrived and went to the AV’s bedroom. The bedroom door was opened and staff entered the room.

· P2 said that there was a sweatshirt tied around the AV’s neck and the AV was not responding to the staffs’ verbal and/or physical prompts. P2 tried to untie the item around the AV’s neck but was unable. P2 called out for someone to retrieve a “seatbelt cutter” from the staff office. The item was retrieved and the sweatshirt was cut away from the AV’s neck. The AV was breathing, and staff found a pulse on the AV’s wrist. The AV was rolled onto his/her side. P2 completed a “sternum rub” by rubbing his/her knuckles along the AV’s ribcage, and the AV responded by waking up. The AV was helped into a sitting position and moved so that his/her back was against the wall.

· P1 also responded to the AV’s bedroom. P1 observed the AV having a shirt tied around his/her neck. The AV had a “weak pulse” and was breathing. The AV’s limbs were “kind of limp.” Once the shirt was removed, the AV became responsive and had a “strong pulse.” The AV’s oxygen saturation (O2 stats) was 100%. The AV’s neck had “some redness” and the AV was “really sweaty.” P1 believed that the shirt was tied “quite tight” in order to leave redness on the AV’s neck; however, P1 also expected that had the shirt been restricting the AV’s oxygen intake, the AV’s O2 stats would not have been 100%. Within minutes the AV was “completely alert, oriented.” P1 and a nursing supervisor determined that the AV did not require emergency medical services and could remain at the facility under constant supervision. P1 also called the facility’s medical doctor who agreed with this assessment.

· P2 said that the AV was placed on “suicide risk,” which meant that s/he would be continuously observed by a staff person until a time when the AV was cleared or removed from suicide risk.

· The facility’s camera footage showed that at 12:27:43 p.m., all staff exited the AV’s bedroom and the door was closed. One staff person remained standing outside the door looking continuously through the window into the room.

· Following this incident, the AV made comments to SP2 that s/he tied the sheet around his/her neck to get a response from staff because the AV was not allowed to make a phone call earlier in the day. The AV told SP3, “You guys would have been in real trouble had it been this was real.”

· P2 said that following the incident, s/he met with SP1-SP3 about what happened. P2 was told that staff saw the AV lying on the floor and they could tell the AV was breathing. P2 said that staff were trained to watch for signs of breathing (e.g. chest rising and falling) and to see skin. P2 added that it was not

uncommon for a youth to ignore staff or act “unresponsive” to get attention. P2 told SP1 that, in the future, if s/he did not know if a situation required a medical back-up, s/he could call P2 to get assistance.

Facility documentation stated that SP1-SP3, P1, and P2 were certified in first aid and CPR, and received training on the Reporting of Maltreatment of Minors Act. SP1-SP3 and P1 also received training on the facility’s policies and procedures, including Visual Well-Being Checks and Medical Emergencies. P2 was not required to receive this training due his/her role at the facility.

Conclusion:

A. Maltreatment:

The AV told this investigator that on November 4, 2022, s/he was upset about being restricted to his/her bedroom. The AV tied a sheet around his/her neck to “act like” s/he was “dead.” The AV then lay on the floor and waited for the staff to respond, but the staff “didn’t care at all.” In response, the AV “tied [the sheet] a little tighter,” which caused him/her to “pass out.” When the AV woke up, s/he saw P2 standing over him/her. The AV was ultimately unharmed.

SP1-SP3 provided information that on November 4, 2022, the AV was “upset” or “pissed” about being restricted to his/her bedroom. At 12 p.m., SP2 checked on the AV, and the AV was lying on his/her bed, unharmed.

At 12:04 p.m., SP1 checked on the AV and found him/her lying on his/her bedroom floor. The AV did not respond to SP1. SP1 saw that the AV was breathing and did not see anything restricting the AV’s breathing or other hazards in the AV’s bedroom. SP1 explained that the AV had a history of ignoring staff when s/he was upset. SP1 believed this was what the AV was doing.

At 12:09 p.m., SP1 and SP2 checked on the AV, who remained lying on the floor and not responding to staff. SP2 saw that the AV was breathing and did not see anything restricting the AV’s breathing or other hazards in the AV’s bedroom. SP1 believed the AV’s arms had changed positions since his/her initial check five minutes prior.

At 12:20:17 p.m., SP1 and SP3 checked on the AV. SP1 still did not see anything tied around the AV’s neck. SP3 told this investigator that s/he saw something tied around the AV’s neck and instructed SP1 to radio a “medical backup.” SP1 and SP3 did not enter the AV’s bedroom at that time, and instead waited for the responding staff.

At 12:21:08 p.m. responding staff arrived including P2 who tried to untie the item from the AV’s neck but was unable and called for a “seatbelt cutter.” When that was brought to P2, the items was cut from the AV’s neck. The AV was breathing, and staff found a pulse on the AV’s wrist. The AV was rolled onto his/her side. P2 completed a “sternum rub” by rubbing his/her knuckles along the AV’s ribcage, and the AV responded by waking up. The AV was helped into a sitting position and moved so that his/her back was against the wall.

The AV did not require emergency medical services.

Information regarding what was tied around the neck varied. The AV said s/he used a sheet; SP3 said it was a towel; P1 said it was a shirt; and P2 said it was a sweatshirt. Therefore, it was not determined what was tied around the AV’s neck.

P1 said that the item tied around the AV’s neck was tight enough to leave redness on the AV’s skin. However, P1 believed that had the AV’s breathing been restricted, his/her O2 stats would have been lower than what they were, which was 100%.

Although ultimately the AV was unharmed and throughout the incident, SP1 believed that the AV was “playing opossum,” the staff did not know this outcome while the incident was unfolding. Between 12:04 and 12:21 (17 minutes), SP1-SP3 each observed the AV unresponsive on the floor, and SP3 observed something tied around the AV’s neck. However, despite this, no one entered the AV’s bedroom or immediately called for help to ensure the AV was unharmed until 12:20 p.m. (16 minutes after the AV was initially observed on the floor). This conduct was inconsistent with the facility’s Medical Emergencies, which stated that staff should respond immediately by checking the scene safety; checking the person for responsiveness; checking the person’s airway, breathing, and circulation; administering first aid as needed; and radioing a “medical back-up.” Given this, and that the item tied around the AV’s neck was tight enough to leave redness and make it so the AV was not immediately awoken by staff and required a “sternum rub", the failure of the staff to act immediately placed the AV at an increased risk of harm or even death, and as such, there was a preponderance of the evidence that there was a failure to provide the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV's physical or mental health.

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2):

When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

On November 4, 2022, SP1-SP3 were assigned to work the AV’s unit. SP1-SP3 were certified in first aid and CPR; and received training on the Visual Well-Being Checks and Medical Emergencies, and on the Reporting of Maltreatment of Minors Act. SP1, SP2, and SP3 each failed at certain points to immediately provide care for the AV. SP1-SP3 were each responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP1-SP3 were responsible did not meet statutory criteria to be determined as recurring or serious. SP1’s-SP3’s actions were considered a single incident of maltreatment for which there was no information the AV sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility’s professional standards and conduct division was conducting an investigation concurrently with this investigation, and would determine any needed corrective actions, including additional trainings. At the completion of this investigation, the professional standards and conduct division had not yet completed their investigation.

Action Taken by Department of Human Services, Office of Inspector General:

SP1-SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 were each notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that SP1-SP3 were each responsible for maltreatment is subject to appeal.

The facility is licensed by the Minnesota Department of Corrections. A copy of this report was forwarded to them for their review of possible licensing violations.

Certification:

The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.

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

doc_type: Maltreatment Finding


state: MN

facility_name: Hoffmann Center

report_date: December 13, 2024

raw_content:
December 13, 2024

Tricia Johnson, Authorized Agent

Hoffmann Center

PO BOX 60

Saint Peter, MN 56082

License Number: 801377 (PRTF)

Report Numbers: 202402067

202402781

CORRECTION ORDER

Dear Tricia Johnson:

On September 23 through 29, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Hoffmann Center, located at 1715 Sheppard Dr., St. Peter, MN 56082. This review was conducted to determine compliance with state and federal laws and rules governing the provision of psychiatric residential treatment facilities under the variance to Minnesota Rules, Chapter 2960; R2960V. 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.

Postings, Physical Plant, Policies, and Practices

1. Violation: The license holder did not comply with maltreatment of vulnerable adult requirements in the following ways:

a. The program abuse prevention plan (PAPP) was not posted in a prominent location in the program on the Wolves unit;

b. The copy of the internal and external reporting policies and procedures posted did not include the internal reporting components;

c. The license holder’s governing body did not review the PAPP at least annually using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review for the annual calendar year 2023; and

d. The license holder’s PAPP did not meet requirements in the following ways:

i. The population assessment did not include:

1) The need for specialized programs of care for clients; and

2) The need for staff training to meet the identified individual needs of the clients; and

i. The physical plant assessment did not include the existence of areas which are difficult to supervise.

Statute Violated: Minnesota Statutes, section 245A.65, subdivisions 1, paragraph (d), and 2, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure postings and the program abuse prevention plan meets all applicable requirements.

2. Violation: The license holder did not ensure that housekeeping and maintenance services were operated on a consistent and healthy basis to ensure the facility was kept clean and in good repair. During the onsite licensing review, DHS licensors observed the following:

a. A dark stained couch and stained toilets in the resident bathrooms;

b. A dining room with food and garbage remnants on the tables, floors, and walls;

c. Seclusion rooms with stained walls, torn and ripped wall paddings, and torn floor tiles; and

d. An outer recreation building with a strong odor similar to mold and mildew.

Rule Violated: Minnesota Variance, section R2960V.20, subparts 2 through 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of housekeeping and maintenance meets all applicable requirements.

3. Violation: The license holder did not develop and monitor the implementation of program policies and procedures as necessary to maintain compliance with licensing requirements under Minnesota Statutes and Rules, for the following areas:

a. Statement of intended use, including a current description of the services to be offered and the target population to be served;

b. Admission criteria, including:

i. How the program considers the program’s staffing patterns and competencies of staff when making a determination concerning whether the program is able to meet the needs of a person seeking admission;

ii. A resident must meet the eligibility criteria outlined in Minnesota Statutes, section 256B.0941, subdivision 1, including being younger than the age of 21 upon admission; and

iii. When a continued stay at the facility is needed, it is the responsibility of the resident’s multidisciplinary treatment team and the clinical director to establish that the requirements for a continued stay have been met;

c. Program rules, including consequences that are in accordance with positive support strategies and evidence-based practices;

d. Restraint and seclusion, including what debriefing documentation must include;

e. Maltreatment reporting, including both the maltreatment of vulnerable adults and the maltreatment of minors. The license holder maintained two policies for the maltreatment of vulnerable adults and two policies for the maltreatment of minors that were duplicative and contradictory; and

f. The Positive Support Rule (PSR), including:

i. A procedure to screen and assess for and determine who qualifies for the PSR; and

ii. Policies and procedures in accordance with Minnesota Rules, chapter 9544, parts 9544.0020 through 9544.0120, that are not duplicative and contradictive.

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 14; 245A.65, subdivision 1; 245A.66; and Minnesota Variance, sections R2960V.04, subpart 1; R2960.10; R2960V.11, subpart 3; R2960V.12, items A through E; R2960V.18, subpart 1, items A and B, and 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program rules meet all applicable requirements. Within 14 days receipt of this order, the license holder must contact their DHS Licensor to discuss compliance requirements pertaining to the areas identified above. Within 45 days thereafter, the license holder must submit revised policies and procedures and a resident handbook to demonstrate compliance for the areas identified above.

4. Violation: The license holder’s internal reviews of alleged or suspected maltreatment of minors did not meet requirements. There was no documentation of an internal review completed for a report of alleged or suspected maltreatment made on March 5, 2024.

Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the internal reviews of alleged or suspected maltreatment meet all applicable requirements.

5. Violation: The license holder failed to ensure the resident’s right to not perform labor or services for the facility was protected. DHS Licensors observed a “chore list” displayed on each living unit identifying that residents were responsible to clean staff bathrooms, seclusion rooms, etc., and the Client and Parent Manual included a list of resident “housekeeping chores”. There was no documentation to demonstrate this was therapeutic or consistent with residents’ treatment plans. Minnesota Statutes, section 144.651, subdivision 23, prohibits residents from performing labor or services for the facility unless those activities are included for therapeutic purposes and appropriately goal-related in the residents’ treatment plan.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item O.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident rights are protected and meet all applicable requirements.

6. Violation: The license holder did not meet requirements governing clinical supervision in the following ways:

a. For two of two weeks reviewed, the license holder did not ensure all treatment team members participated either in clinical supervision or an ancillary meeting for each calendar week they worked, for the weeks of:

i. February 25, 2024, when 23 staff persons did not attend; and

ii. July 21, 2024, when 47 staff persons did not attend; and

b. For the week of February 25, 2024, there was no documentation demonstrating a clinical supervision meeting was held for the Wolves unit.

Rule Violated: Minnesota Variance, section R2960V.13.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision for program staff meets all applicable requirements.

7. Violation: The license holder did not meet requirements governing staff ratios in the following ways:

a. The required ratio of one staff to every three residents during awake hours within each living unit was not met for the following dates and living units:

i. February 12, 2024 (Falcons);

ii. March 29, 2024 (Falcons);

iii. March 31, 2024 (Falcons);

iv. July 5, 2024 (Phoenix);

v. July 12, 2024 (Phoenix);

vi. July 15, 2024 (Knights);

vii. July 19, 2024 (Knights, Falcons, and Wolves); and

b. The required ratio of one staff to every six residents during sleeping hours within each living unit was not met for the following dates and living units:

i. February 21, 2024 (Falcons);

ii. February 22, 2024 (Falcons); and

iii. July 24, 2024 (Phoenix).

Rule Violated: Minnesota Variance, section R2960V.14, subparts 1 through 3.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff ratios meet all applicable requirements. Within 60 days receipt of this order, submit two consecutive weeks of unit staff schedules and the corresponding daily resident census per each living unit to demonstrate compliance.

8. Violation: The license holder did not meet quality assurance and improvement requirements in the following ways:

a. The license holder did not complete a review of the data or information related to the following required components every three months/quarterly:

i. Resident outcomes, including identifying ways to improve effectiveness of the services provided to residents and to improve resident outcomes (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarters 1 and 2 of 2024);

ii. Restraint data, according to part R2960V.11 (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024);

iii. Serious occurrences and other significant incidents, including (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024):

1) Determining whether policies and procedures were followed;

2) Evaluating the staff’s response to the serious occurrence and other significant incidents;

3) Assessing what could have prevented the serious occurrence and other significant incidents from occurring; and

4) Modifying policies, procedures, training plans, or resident’s ITPs in response to the findings of the review; and

iv. Self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF Variance, R2960V, and demonstrating action to improve the program’s compliance with the requirements (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarters 1 and 2 of 2024);

b. The license holder did not at least annually review, evaluate, and update the quality assurance and improvement plan for 2022 and 2023; and

c. The license holder did not at least annually meet with community leaders representing the area where the facility is located to advise them about the nature of the programs, types of residents served, the results of the services the program provided to the residents, the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months for the annual years 2022 and 2023.

Rule Violated: Minnesota Variance, section R2960V.17

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quality assurance and improvement plan meets all applicable requirements.

9. Violation: The license holder did not complete a quarterly review of the patterns of the use of restraint and seclusion procedures (Quarter 4 of 2022, Quarters 1 through 4 of 2023, and Quarter 2 of 2024) that considered the following:

a. Any patterns or problems indicated by similarities in the time of day, day of the week, duration of the use of a procedure, individuals involved, or other factors associated with the use of restraint and seclusion procedures;

b. Any injuries resulting from the use of restraint and seclusion procedures;

c. Actions needed to correct deficiencies in the program's implementation of restraint and seclusion procedures;

d. An assessment of opportunities missed to avoid the use of restraint and seclusion procedures; and

e. Proposed actions to be taken to minimize the use of restraint and seclusion.

Rule Violated: Minnesota Variance, section R2960V.11, subpart 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the review of the patterns of the use of restraint procedures meet all applicable requirements.

10. Violation: The license holder did not establish a mechanism or procedure to ensure that their use of electronic record keeping, including electronic signatures, did not compromise the security of the residents records. DHS Licensors observed that the electronic record system did not lock or secure the document from further alteration once it was electronically signed by the writer and/or the mental health professional and medical director for final approval and completion.

Statute Violated: Minnesota Statutes, section 245A.041, subdivision 4 paragraph (4).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the use of electronic record keeping meets all applicable requirements.

Personnel Files

11. Violation: Eight of eight personnel files reviewed for requirements governing training for staff providing services to individuals who qualify for the Positive Support Rule (PSR) did not meet requirements in the following ways:

a. At least eight hours of core training was not completed for staff persons responsible for developing, implementing, monitoring, supervising, and/or evaluating positive support strategies, a positive support transition plan, and/or the emergency use of manual restraint prior to the staff person assuming responsibilities (personnel files numbered 1, 5, 6, and 13);

b. Staff persons were not trained to the following required core training topics:

i. What constitutes the use of restraint, including mechanical restraint, time-out, and seclusion (personnel file numbered 1);

ii. Staff responsibilities related to prohibited procedures; why the procedures are not effective for reducing or eliminating symptoms or interfering behavior; and why the procedures are not safe (personnel file numbered 1);

iii. Staff responsibilities related to restricted and permitted actions and procedures (personnel file numbered 1);

iv. The situations in which staff must contact 911 services in response to an imminent risk of harm to the person or others (personnel file numbered 1);

v. The procedures and forms staff must use to monitor and report use of restrictive interventions that are part of a positive support transition plan (personnel file numbered 1);

vi. The procedures and requirements for notifying members of the person’s expanded support team after the use of a restrictive intervention (personnel file numbered 1);

vii. Understanding of the person as a unique individual and how to implement treatment plans and responsibilities assigned to the license holder (personnel file numbered 9);

viii. Cultural competence (personnel file numbered 1); and

ix. Personal staff accountability and staff self-care after emergencies (personnel files numbered 1, 2, 5, 6, 9, and 12 through 14);

c. An additional four hours of function-specific training based upon the level of responsibility and qualifications, prior to assuming responsibilities, for staff persons who develop positive support strategies and program managers, was not completed on the following required topics (personnel file numbered 1):

i. Functional behavior assessments;

ii. How to apply person-centered planning;

iii. How to design and use data systems to measure effectiveness of care; and

iv. Supervision, including how to train, coach, and evaluate staff and encourage effective communication with the resident and the resident’s support team;

d. A minimum of an additional two hours of function-specific training for staff persons in manager positions was not completed on the following required topics (personnel file numbered 1):

i. How to include staff in organizational decisions;

ii. Management of the organization based upon person-centered thinking and practices and how to address person centered thinking and practices in the organization; and

iii. Evaluation of organizational training as it applies to the measurement of behavior change and improved outcomes for persons receiving services; and

e. Four hours of refresher training covering each of the core training topics and the function-specific training topics applicable to the staff and their responsibilities was not completed on an annual basis, for 2023 and 2024 (personnel files numbered 1, 2, 5, 6, 9, and 12 through 14).

Rule Violated: Minnesota Rules, part 9544.0090, subparts 1 through 5; and Minnesota Variance, section R2960V.02, subpart 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff training for the PSR meets all applicable requirements.

12. Violation: Eleven of twelve personnel files reviewed for requirements governing background study subjects and staff files did not meet requirements. The files did not include:

a. An application for employment or resume (personnel files numbered 3, 7, 9, and 10);

b. Verification of the staff persons qualifications specific to the position including required credentials and/or professional licensure (personnel files numbered 3 and 10);

c. The date of hire (personnel file numbered 1);

d. Job description (personnel file numbered 1);

e. Documentation of orientation (personnel file numbered 12);

f. The first date the background study subject/staff person began working in the license holder’s facility (personnel file numbered 1);

g. The first date the background study subject/staff person had direct contact with persons served by the license holder’s program (personnel files numbered 1, 3, 5, and 12);

h. An annual job performance evaluation (personnel files numbered 1 and 5); and

i. An annual development and training plan (personnel files numbered 1, 2, 4, 6, and 11).

Statute and Rule Violated: Minnesota Statutes, section 245A.041, subdivision 6, and Minnesota Variance, section R2960V.15, subpart 5.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the inclusion of background study requirements and staff files meet all applicable requirements.

13. Violation: Two of four personnel files reviewed for requirements governing orientation training did not meet requirements. The staff person did not receive orientation to the following prior to direct contact:

a. Resiliency and recovery concepts and principles (personnel files numbered 4 and 8); and

b. Gender based needs (personnel file numbered 4).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 2, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of orientation training meets all applicable requirements.

14. Violation: Three of seven personnel files reviewed for requirements governing annual training did not meet requirements. The staff person did not receive annual training to the following:

a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, section 245A.65, subdivision 3, and 626.557 and 626.5572, and the license holder’s program abuse prevention plan (PAPP) (personnel files numbered 1 and 5); and

b. Resident rights as identified in part R2960V.04 (personnel files numbered 1, 5, and 12);

c. Emergency procedures (personnel files numbered 1 and 12);

d. Treatment services for residents with co-occurring disorders (personnel files numbered 1, 5 and 12) and

e. A minimum of four additional training subjects identified in R2960V.16, subpart 3, for a staff who is not a licensed mental health professional or licensed independent practitioner (personnel file numbered 12).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of annual training meets all applicable requirements.

15. Violation: Twelve of twelve personnel files reviewed for requirements governing documentation of orientation and training did not meet requirements. The documentation did not include:

a. The amount of time the training was provided (personnel file numbered 11 and 12); and

b. The names and credentials of the people who certified the completion of the training (personnel files numbered 1 through 12).

Rule Violated: Minnesota Variance, section R2960V.16, subpart 6.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

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

Resident Files

16. Violation: One resident file reviewed for requirements governing the Positive Support Rule (resident file numbered 5) did not meet requirements in the following ways:

a. The license holder utilized a prohibited action and/or procedure for a behavioral or therapeutic program to reduce or eliminate a behavior. The use of time-out was implemented on April 27, 2023; and

b. The license holder did not provide written notice to the resident and their legal representative, at the time-of-service initiation, of the license holder’s policy on the emergency use of restraints that included the person’s rights under the PSR and Minnesota Statues 245D.04.

Rule Violated: Minnesota Rules, parts 9544.0030, subpart 1, 9544.0040, subparts 2 and 3, 9544.0080, subparts 1 and 2, 9544.0070, subpart 3, and 9544.0110; and Minnesota Variance, section R2960V.02, subpart 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of PSR meets all applicable requirements.

17. Violation: One resident file reviewed for requirements governing individual abuse prevention plan (resident file numbered 4) did not meet requirements in the following ways:

a. An individual abuse prevention plan (IAPP) was not developed as part of the initial service plan;

b. The IAPP did not contain an individualized assessment of the person’s susceptibility to abuse by others, including other vulnerable adults;

c. The IAPP did not include detailed measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors to the facility and persons outside the facility, if unsupervised, for a vulnerable adult who was known by the facility to have committed acts of physical aggression towards others; and

d. Documentation did not demonstrate that the resident participated in the development of the IAPP.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 11 paragraph (c), 245A.65, subdivision 2, paragraph (b).

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 30 days receipt of this order, submit an IAPP template that meets all applicable requirements to demonstrate compliance.

18. Violation: Three of three resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways:

a. The immediate needs assessment and preliminary plan of care was not completed within 24 hours (resident files numbered 1 and 3);

b. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize safety risks (resident files numbered 1 through 3);

c. Documentation in the plan of care could not demonstrate if the plan was updated to reflect the resident’s changing condition. The plan contained contradictory information, indicating significant treatment disruptions were occurring and that the resident was improving and no changes were needed for plans dated December 10, 2023 and January 10, 2024. (resident file numbered 1);

d. The plan of care was not reviewed at least every 30 days. The plan was reviewed late on July 15, 2024, when it was due by July 12, 2024 (resident file numbered 3);

e. Treatment objectives were not measurable and did not include target dates for achievement (resident files numbered 1 through 3);

f. Strategy interventions were not specific to reach each objective (resident files numbered 1 and 2);

g. Strategy interventions did not identify the frequency they were to be implemented (resident files numbered 1 and 2);

h. The medication management treatment goal did not identify specific interventions and associated frequencies that the medication prescriber was to be responsible for (resident files numbered 1 through 3);

i. There was no documentation to demonstrate an individual support plan was developed for individuals that displayed behaviors that might require the use of restraint or seclusion (resident files numbered 1 through 3); and

j. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (resident file numbered 1).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, items A and B.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 30 days receipt of this order, submit an Individual Plan of Care and Individual Support Plan for one resident that meets all applicable requirements to demonstrate compliance.

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

a. There was no documentation to demonstrate that individual therapy was provided a minimum of twice per week for treatment weeks:

i. February 11, 2024 (resident file numbered 1); and

ii. February 20, 2024 (resident file numbered 2);

b. There was no documentation to demonstrate that family engagement activities were provided a minimum of one time per week for weeks:

i. February 11 and March 3, 2024 (resident file numbered 1);

ii. February 20 and 26, 2024 (resident file numbered 2); and

iii. June 18 and September 17, 2024 (resident file numbered 3); and

c. Documentation didn’t demonstrate that supportive services for daily living and safety were provided as required (resident files numbered 1 and 2).

Rule Violated: Minnesota Variance, section R2960V.06, subparts 1, and 4, item C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

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

20. Violation: Four of four resident files reviewed for requirements governing health care services and medication, medication reconciliation, and medication administration did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the health needs of the resident were addressed and monitored on an on-going basis when resident had an asthma attack during a manual restraint (resident file numbered 3);

b. Medication reconciliation was not completed upon admission (resident files numbered 1 through 3) and upon discharge (resident file numbered 2); and

c. Prescription medicine belonging to a resident was not documented to have been either given to the resident’s legal guardian or to the resident who was 18 years of age upon their discharge (resident files numbered 2 and 4);

Rule Violated: Minnesota Variance, section R2960V.08, subpart 2, item B, subpart 3, and subpart 4, item D.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

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

21. Violation: Three of three resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways (resident files numbered 1 through 3):

a. The prescribing practitioner did not document the following required information:

i. A description in observable and measurable terms of the symptoms and behaviors the psychotropic medication is to alleviate;

ii. Data collection methods the license holder must use to monitor and measure changes in symptoms and behaviors that are to be alleviated by the psychotropic medication; and

iii. A psychotropic medication review was completed at least weekly for the first month and every month thereafter; and

b. Resident file documentation did not demonstrate that the license holder considered the following for each psychotropic medication review conducted by the prescribing practitioner:

i. Targeted symptoms and behaviors of concern;

ii. Data collected since the last review; and

iii. Side effects observed and actions taken.

Rule Violated: Minnesota Variance, section R2960V.08, subpart 6, items B and C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

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

22. Violation: Three of three resident files reviewed for requirements governing medication side effect monitoring did not meet requirements in the following ways:

a. The license holder did not document and monitor for side effects within 24 hours of admission (resident files numbered 1 and 3);

b. Documentation did not demonstrate that the nurse determined and documented the frequency of side effect monitoring within the resident file (resident files numbered 1 through 3); and

c. Documentation did not demonstrate that the license holder monitored for side effects as determined by the prescribing practitioner when the following occurred (resident files numbered 1 through 3):

i. A new psychotropic medication was ordered for the resident; and

ii. A psychotropic medication had been discontinued.

Rule Violated: Minnesota Variance, section R2960V.08, subpart 10.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of medication side effects meet all applicable requirements.

23. Violation: Three of three resident files reviewed for requirements governing documentation standards for the use of restraint and seclusion did not meet requirements in the following ways:

a. Documentation did not include why less restrictive interventions attempted had failed or were found to be inappropriate (resident files numbered 1 and 2); and

b. There was no documentation for the use of a restraint that had occurred on August 22, 2024 (resident file numbered 3).

Rule Violated: Minnesota Variance, section R2960V.11, subpart 2.

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

24. Violation: Three of three resident files reviewed for requirements governing debriefings for the use of restraint and seclusion did not meet requirements. The debriefing following the use of restraint and seclusion did not meet requirements in the following ways:

a. Documentation did not demonstrate whether additional staff training resulted from the debriefings (resident files numbered 1 and 2);

b. Documentation did not demonstrate whether the license holder provided the resident with an opportunity to have a legal representative or advocate participate in the debriefing on the following dates the use of restraint or seclusion occurred:

i. February 2, 2024 (resident file numbered 1); and

ii. February 28, 2024 (resident file numbered 2);

c. The license holder did not document a response and rationale when the license holder’s documentation indicated they were unable to accommodate participation of the resident’s legal representative or advocate for the use of restraint or seclusion on February 18, 2024 (resident file numbered 2);

d. Precipitating factors and alternative techniques that might have prevented the use of restraint or seclusion were not incorporated into the resident’s individual support plan to prevent future use (resident files numbered 1 through 3); and

e. Documentation did not include the evaluation of the circumstances that caused an injury during a safety intervention nor the plan that must be developed to prevent future injuries (resident file numbered 2).

Rule Violated: Minnesota Variance, section R2960V.11, subpart 3, items A through D.

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

25. Violation: Two of two resident files reviewed for requirements governing discharge and aftercare plans did not meet requirements in the following ways:

a. Documentation did not demonstrate that the discharge plan was developed at least 10 days before discharge (resident file numbered 4);

b. The aftercare plan did not include the following:

i. Medical needs including allergies (resident file numbered 4);

ii. Medication, dosage, clinical rationale, and name of the prescriber (resident file numbered 2 and 4);

iii. Discharge diagnosis and treatment summary (resident file numbered 4);

iv. Prevention plan to address symptoms of harm to self or others (resident files numbered 2 and 4); and

v. Contact information for the PRTF educational provider (resident files numbered 2 and 4); and

c. There was no documentation to demonstrate the license holder shared documents related to the resident’s care in their facility to any mental health providers who will be providing aftercare services (resident file numbered 2).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, items B and C.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

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

26. Violation: Two of two resident files reviewed for requirements governing documentation standards did not meet requirements in the following ways:

a. Documentation in the resident’s file did not include direct care and nursing staff person’s titles (resident files numbered 1 through 3);

b. A mental health professional did not co-sign and date required treatment service notes for a clinical trainee who provided treatment services to a resident on February 8 and 21, 2024 and March 6, 7, and 8, 2024 (resident file numbered 2);

c. A daily summary was not completed for each day sampled:

i. February 22, 2024, and March 3, 4, 5, and 9, 2024 (resident file numbered 1); and

ii. December 12, 2023, and January 4, 5, 14, 17, and 19, 2024 (resident file numbered 3); and

d. Documentation did not demonstrate case coordination activities occurred with other professionals, including case managers and community-based mental health providers, or others (resident files numbered 1 and 2).

Rule Violated: Minnesota Variance, section R2960V.06, subpart 1, item C, and R2960V.19, subparts 2 through 4.

Repeat Violation: In a Correction Order that DHS issued on February 27, 2023, you were previously found in violation of this same statute.

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

27. Violation: Two of two resident files reviewed for requirements governing the no eject policy (resident files numbered 1 and 2) did not meet requirements. Documentation did not demonstrate:

a. Whether the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder; and

b. The reasons that the decision to discharge was warranted and any alternatives considered or attempted.

Rule Violated: Minnesota Variance, section R2960V.07, subpart 4.

Repeat Violation: In a Correction Order that DHS issued on April 11, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure no-eject documentation meets all applicable requirements.

Written Response Required

If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

Submissions required as part of the corrective action ordered must be sent to your licensor by email at tina.christensen@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6610 or at tina.christensen@state.mn.us .

Sincerely,

Tina Christensen, 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


facility_name: Hope Harbor

raw_content:
March 17, 2025

Melissa Bruns, Authorized Agent

Hope Harbor

219 N. High St.

Marshall, MN 56258

License Number: 1036261 (CRF)

CORRECTION ORDER

Dear Melissa Bruns:

On January 27 through 29, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Hope Harbor, located at 219 N. High St., Marshall, MN, 56258. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, and group residential settings under Minnesota Rules, parts 2960.0130 through 2960.0220. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Policies and Procedures and Practices

1. Violation: The license holder’s written program descriptions, and policies and procedures that implement the program described, did not meet requirements. The descriptions suggest that participating in and attending spiritual and religious components and activities of the program is required, and that lack thereof, is considered as a basis for privileges in the facility. Residents and staff reported this to be their understanding as well. Additionally, the offering of alternative programming components and activities described by the license holder during the onsite licensing review were not included in the program descriptions or policies and procedures.

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 8, item A; 2960.0160, subpart 4, items A and B; and 2960.0180, subpart 2, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the written program descriptions and policies and procedures that implement the program described meet all applicable requirements. Within 30 days of receipt of this order, submit revised program descriptions and applicable policies and procedures that demonstrate compliance.

2. Violation: The license holder’s plan for transfer of clients and records upon closure did not meet requirements for the transfer of closed case records in the following ways:

a. The plan did not include either a signed agreement or other documentation indicating that a county or similarly licensed provider has agreed to accept and maintain the program’s closed case records if the organization closes; and

b. The plan included a statement that the license holder would maintain client records for up to one year, however, Minnesota Statutes, section 245A.041, subdivision 3, requires a license holder to maintain all records related to the licensed program, including client records, for five years from the date of closure.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the plan for transfer of clients and records upon closure meets all applicable requirements. Within 30 days of receipt of this order, submit a revised plan for transfer of clients and records upon closure that demonstrates compliance.

3. Violation: The license holder’s grievance procedure did not meet requirements in the following ways:

a. It did not indicate that upon receiving a compliant, the license holder would give the person who wants to make a grievance, the necessary forms to file the grievance; and

b. It did not include that a person filing a grievance would receive a response within five days from the initial date of the compliant.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A.

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

4. Violation: The license holder’s annual training plan did not meet requirements. The plan did not include how the license holder determines the amount of training that is needed for a volunteer based upon the position description, tasks to be performed, and the performance indicators of the position, including the amount of in-service training per year for a volunteer consistent with their duties and directly related to the needs of children in their care.

Rule Violated: Minnesota Rules, part 2960.0150, subpart 4, items A and B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual training plan meets all applicable requirements.

5. Violation: An internal review for a report of alleged or suspected maltreatment of a minor, dated October 2, 2023, was not completed within 30 calendar days from when the report was made.

Statute Violated: Minnesota Statutes, section 245A.66.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the internal review for an alleged report of maltreatment of a minor meets all applicable requirements.

6. Violation: The license holder did not provide for the safe storage and delivery of medications. The license holder allowed for over-the-counter medications to be administered to residents without a written order by a prescribing physician.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the administration of medications meet all applicable requirements. Within 30 days of receipt of this order, submit a revised plan for the safe storage and delivery of medicine and applicable template(s)/form(s) for obtaining written medication orders and for recording the administration of medications that demonstrates compliance.

Repeat Violation: In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement.

Personnel Files

7. Violation: Two of five personnel files reviewed for requirements governing the provision of background studies did not meet requirements in the following ways:

a. As a result of a licensing review, a DHS Licensor determined that the license holder failed to submit a background study before an adult, regardless of whether the individual will have direct contact with persons served by the children’s residential facility, began working in the facility or setting and allowed for the staff person to have access to people served by the program before a BGS notice was issued:

i. SP1 began working in a children’s residential facility on August 19, 2024, however, the license holder did not submit a BGS request to DHS for SP1 until August 24, 2024, and a BGS notice was not issued until August 31, 2024.

Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), except for BGS violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a BGS violation before the commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a BGS violation may not avoid a fine for a subsequent BGS violation unless at least 365 days have passed since the license holder self-corrected the earlier BGS violations.

Because the license holder self-corrected the background study violation involving SP1 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP1; and

b. The license holder did not document the first date that a person who is a background study subject begins working in the license holder’s facility or setting (personnel files numbered 1 and 3).

Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 11, 245C.13, subdivision 2, and 245A.041, subdivision 5.

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

8. Violation: One of two personnel files reviewed governing annual training (personnel file numbered 4) did not meet requirements. Training was not completed annually, for calendar years 2023 and 2024, to the following:

a. Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572;

b. All internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults receiving services; and

c. The license holder’s program abuse prevention plan (PAPP).

Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of annual training meets all applicable requirements.

Resident Files

9. Violation: One of three resident files reviewed for requirements governing the administration of medication (resident file numbered 1) did not meet requirements in the following ways:

a. The license holder did not document and follow the prescribing physician’s directions for monitoring medications used by the resident in the following ways:

i. A medication change was noted on the medication administration record (MAR) in the month of August 2024, however, there was not an order for the medication change in the resident’s file;

ii. The directions for administering a medication on the resident’s MAR did not match the physicians order, dated July 12, 2024, for the time of the day the medication was to be administered; and

b. The records for a resident who receives prescription drugs at the facility did not meet requirements in the following ways:

i. In the month of June 2024, medications were documented to have been given on a date that the resident had not been in admittance to the program and there was no documentation to demonstrate medications were administered on a day the resident was identified as present in the facility; and

ii. In the month of August 2024, a medication appeared to have been documented as given, however, there was a line drawn through with no notes indicating if the medication was administered or not.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of medication administration meets all applicable requirements.

Repeat Violation: In a Correction Order that DHS issued on June 30, 2021, you were previously found in violation of this same rule requirement.

10. Violation: One resident file reviewed governing discharge requirements (resident file numbered 3) did not meet requirements. The license holder did not document the inventory of the property returned to the resident at discharge to demonstrate any discrepancies between the admission inventory and the discharge inventory.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the inventory of a resident’s belongings at discharge meets all applicable requirements.

Written Response Required

If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

Submissions required as part of the corrective action ordered must be sent to your licensor by email at tina.christensen@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6610 or at tina.christensen@state.mn.us .

Sincerely,

Tina Christensen, Lead Licensor

Licensing Division

Office of Inspector General

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