report_date: January 31, 2023

raw_content:
January 31, 2023

Eric Vagle, Authorized Agent

Minnesota Adult & Teen Challenge - Lakeside Academy

740 East 24th Street

Minneapolis, MN 55404

License Number: 1078609 (CRF)

Investigation Report Number: 202110234

AMENDED CORRECTION ORDER

Dear Eric Vagle:

On March 15, 2022, a licensing investigation of Lakeside Academy, located at 100 Garrison Avenue NE, Buffalo, MN 55313, was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, (Rule CRF).

As a result of this investigation, a Correction Order was issued on June 10, 2022. The Department of Human Services (“DHS”), Division of Licensing received your request for reconsideration for citations 1 through 3 of that Correction Order on June 10, 2022. On October 12, 2022, DHS issued a Reconsideration Response Correction Order. This Amended Correction Order reflects the final agency decision. Citation 1 as to violation (c) was rescinded from the Correction Order issued on June 10, 2022. This Amended Correction Order supersedes the Correction Order issued on June 10, 2022, which must be destroyed.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

1. Citation: Minnesota Rules, parts 2960.0050, subpart 1, item 0, and 2960.0020, subpart 31.

Violation: The license holder did not meet requirements of ensuring basic rights in the following ways:

a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as, a designated amount of time, in hours, to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds, and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments that are meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the individual treatment plan.

b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2021, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and Corrective Action LASH 330 policy indicates that a resident can earn 1 service hour for cussing/swearing and that the amount of service hours assigned for each behavior increases as the resident advances in their treatment level. For example, residents on level 2 will be assigned 2 service hours and residents on level 4 will be assigned 4 service hours for the same behavior.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all resident’s rights are protected and any discipline implemented meets all applicable requirements.

2. Citation: Minnesota Rules, part 2960.0080, subpart 4, items A and B.

Violation: The license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior.

All of the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours”, and the description of a “service hour” and other consequences that would be applied, were not indicated in writing to the resident in the Resident Handbook: Behavior and Corrective Action LASH 330 policy.

Additionally, the license holder’s Facility Rules and Due Process System and Consequence policies did not align with the current disciplinary/consequence policies and practices that were described through investigative interviews and that are outlined in the Resident Handbook and the Standard Operating Procedures for MnTC Staff.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the facility’s rules and due process system for residents meets all requirements. Within 30 days of receipt of this order, submit to DHS for approval:

· Revised policies and resident handbook that outlines which behaviors are acceptable and unacceptable, and what consequences will be applied. The consequences that will be applied need to be reasonable consequences.

Within 30 days of DHS approval, submit documentation demonstrating the following:

· All staff have been trained on all policies and procedures pertaining to discipline; and

· All youth have been provided verbal and written communication on which behaviors are acceptable and unacceptable, and what consequences will be applied.

3. Citation: Minnesota Rules, parts 2960.0080, subpart 8, item A

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

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of spirituality services meets all applicable requirements. Within 15 days receipt of this order, the license holder must contact DHS licensing to schedule a meeting to discuss and review the variance pertaining to required religious services.

If you fail to correct the violations 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 a corrective action ordered must be sent to DHS Licensing at:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Final Agency Decision

As stated above, this Amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated June 10, 2022. As such, the decision is not subject to appeal.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Tina Christensen, Human Services Licensor

Licensing Division

Office of Inspector General

651-431-6610

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: Lakeside Academy

report_date: October 12, 2022

raw_content:
October 12, 2022

Eric Vagle, Authorized Agent

Minnesota Adult & Teen Challenge – Lakeside Academy

740 East 24th Street

Minneapolis, MN 55404

License Number: 1078609 (CRF)

Investigation Report Number: 202110234

Dear Eric Vagle:

On July 5, 2022, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of all three citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on June 10, 2022.

Citation 1: The correction order stated the license holder did not meet requirements of ensuring basic rights in the following ways:

a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as a designated amount of time in hours to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the treatment plan.

b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2201, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and Corrective Action LASH 330 policy indicates that a resident can earn 1 service hour for cussing/swearing and that the amount of service hours assigned for each behavior increases as the resident advances in their treatment level. For example, residents on level 2 will be assigned 2 service hours and residents on level 4 will be assigned 4 service hours for the same behavior.

c. Additionally, the license holder’s Service Hours policies and practices and the Community Hours policies and practices are not clearly distinguishable. They have an alikeness that creates confusion and a level of contradiction. One is a consequence while the other is a requirement to complete treatment, yet both entail completion of assigned amounts of time for alike tasks.

Request for Reconsideration. The program submitted information and documentation to support the belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder asserted it did not fail to ensure the basic rights of residents and that service tasks are not required to be related to the behavior the intervention was meant to address.

Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0050, subpart 1, item O, a resident has basic rights, including, but not limited to, if applicable, the rights stated in Minnesota Statutes, sections 144.651 and 253B.03. The license holder must ensure the rights in items A to R are protected. Pursuant to Minnesota Rules, part 2960.0020, subpart 31, “discipline” means the use of reasonable, age-appropriate consequences designed to modify and correct behavior according to a rule or system of rules governing conduct.

With regard to violation a, because the program provides substance use treatment services, Minnesota Statutes, section 144.651 applies. That section specifies in subdivision 23 that residents should not perform labor or services for the facility unless those activities are included for therapeutic purposes and appropriately goal-related in their individual medical record. The license holder assigned tasks that included washing dishes, serving meals, collecting garbage and cleaning up after animals which are labor and services for the facility. Those specific tasks were not consistently assigned for therapeutic purposes and were assigned as a consequence that as not consistent with the resident’s case plan. As a result, it is appropriate to affirm the citation.

With regard to violation b, “discipline” is defined as the use of consequences which are “reasonable.” Reasonable is commonly defined to mean fair and sensible or appropriate. The violation was issued because facility documentation indicated that when two residents engaged in the same behavior (being disruptive past room time), one of the residents earned four service hours while the other only earned one. Facility policy indicated that residents on different treatment levels earned different amounts of service hours for the same behavior. As a result, the use of consequences was not reasonable because residents did not receive the same consequences for the same behavior, and it is appropriate to affirm the violation.

There is therefore sufficient evidence to support the citation as to violations a and b, and those violations are affirmed.

With regard to violation c, information submitted with the reconsideration request and further review shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind violation c.

Citation 2: The correction order stated that the license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior.

All the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours,” and the description of a “service hour” and other consequences that would be applied were not indicated in writing to the resident in the Resident Handbook: Behavior and Corrective Action LASH 330 policy. Additionally, the license holder’s Facility Rules and Due Process System and Consequence policies did not align with the current disciplinary/consequence policies and practices that were described through investigative interviews and outlined in the Resident Handbook and the Standard Operating Procedures for MNTC Staff.

Request for Reconsideration. The program submitted information and documentation to support the belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder indicated that all residents are provided with copies and oriented to appropriate facility policy. Additionally, the license holder indicated policies are clearly stated and consistent.

Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0080, subpart 4, items A and B, the license holder must communicate verbally and in writing to a resident who is capable of understanding the facility’s rules and the details of the due process system used in the facility. The rules must address which behaviors are considered acceptable and unacceptable and the reasons why and the consequences that will be applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior. Minnesota Statues, section 245A.04, subdivision 14, paragraph (b), provides that a license holder shall monitor implementation of policies and procedures by program staff.

The license holder indicated in the request for reconsideration that the facility’s Lakeside Academy Policy and Procedure Manual specifically explains unacceptable behaviors and provides detail regarding the consequences of unacceptable behaviors. However, during the investigation, the license holder indicated that residents receive the Resident Handbook, which is contained in the Lakeside Academy Policy and Procedure Manual as a separate section. The license holder verified that the Resident Handbook was the only written documentation or manual provided to residents, and the license holder did not indicate that they provided residents with a copy of the Lakeside Academy Policy and Procedure Manual. The Resident Handbook does not clearly describe the facility’s discipline practices or all of the behaviors that would result in consequences. Additionally, while another policy entitled Predictable Responses provide more detailed information about behaviors that result in consequences, that policy was in a manual reported to be a guide for staff. The Predicable Responses policy was not provided to residents, and the policy did not align with the information in the Resident Handbook. As a result, it is appropriate to affirm the citation.

There is therefore sufficient evidence to support the violation, and it is affirmed. Additionally, the citation is amended to include Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) as additional authority for the violation.

Citation 3: The correction order stated that the license holder did not meet requirements for spirituality services and counseling. The license holder considered the residents’ lack of attendance at religious services as a basis for privileges in the facility. According to the Resident Handbook (LASH 330 & 840) and resident (R2 through R4) and staff (SP2 and SP3) investigative interview, religious services are considered a type of scheduled programming and skipping or refusing programming leads to a consequence of “service hours” and loss of privileges.

Request for Reconsideration. The program submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder indicates that while the program involves spiritual services, parents are required to execute a consent form on behalf of residents, and a variance was approved acknowledging that faith-based programming is an integral part of the program. The license holder denies that any alleged punishment was based on a resident refusing to attend a spiritual service and indicates that “service hours” are assigned for residents failing to attend any scheduled programming.

Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0080, subpart 8, item A, residents must be given an opportunity to participate in spirituality services, activities, and counseling on a voluntary basis. A resident must not be required to attend the services or activities. All spirituality services and activities must be held in a location that the residents who do not wish to participate are not exposed to the services or activities. Attendance or lack of attendance at religious services or activities must not be considered as a basis for any right or privilege in the facility. Pursuant to Minnesota Rules, part 2960.0050, subpart 1, item O, a resident has basic rights, including, but not limited to, if applicable, the rights stated in Minnesota Statutes, sections 144.651 and 253B.03. The license holder must ensure the rights in items A to R are protected.

Although a variance was approved to allow the program to “require the residents to participate in spirituality services” as part of the faith-based programming, it does not indicate that the license holder is permitted to consider the lack of attendance as a basis for privileges in the facility. Additionally, receiving consequences due to not attending spirituality programming is a violation of a resident’s right to refuse care according to the Healthcare Bill of Rights under Minnesota Statutes, section 144.651, subdivision 12. As a result, it is appropriate to affirm the citation.

There is therefore sufficient evidence to support the violation, and it is affirmed. Additionally, the citation is amended to add Minnesota Rules, part 2960.0050, subpart 1, item O, as additional authority for the citation.

Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the following citations, and they are affirmed: citation 1 as to violations a and b; citation 2; and citation 3. The Commissioner finds it is appropriate to rescind citation 1 as to violation c.

This is a final agency decision.

Sincerely,

Frances Simon Standing, Attorney

Legal Counsel’s Office

Office of Inspector General

cc: Jennifer A. Forbes, Attorney

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

doc_type: Document


raw_content:
June 10, 2022

Eric Vagle, Authorized Agent

Minnesota Adult & Teen Challenge - Lakeside Academy

740 East 24th Street

Minneapolis, MN 55404

License Number: 1078609 (CRF)

Investigation Report Number: 202110234

CORRECTION ORDER

Dear Eric Vagle:

On March 15, 2022, a licensing investigation of Lakeside Academy, located at 100 Garrison Avenue NE, Buffalo, MN 55313, was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, (Rule CRF). As a result of this licensing investigation a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

1. Citation: Minnesota Rules, parts 2960.0050, subpart 1, item 0, and 2960.0020, subpart 31.

Violation: The license holder did not meet requirements of ensuring basic rights in the following ways:

a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as, a designated amount of time, in hours, to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds, and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments that are meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the individual treatment plan.

b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2021, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and Corrective Action LASH 330 policy indicates that a resident can earn 1 service hour for cussing/swearing and that the amount of service hours assigned for each behavior increases as the resident advances in their treatment level. For example, residents on level 2 will be assigned 2 service hours and residents on level 4 will be assigned 4 service hours for the same behavior.

c. Additionally, the license holder’s Service Hours policies and practices and the Community Hours policies and practices are not clearly distinguishable, they have an alikeness that creates confusion and a level of contradiction as one is a consequence, while the other is a requirement to complete treatment, yet both entail completion of assigned amounts of time for alike tasks.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all resident’s rights are protected and any discipline implemented meets all applicable requirements. Within 30 days of receipt of this order, submit to DHS for approval:

· Revised policies and practices for Service Hours and Community Hours that are clearly distinguishable, non-contradictory, and that ensure all resident’s rights are protected, and all discipline implemented meets all applicable requirements.

Within 30 days of DHS approval, submit documentation demonstrating the following:

· All staff have been trained on the approved policies and procedures.

2. Citation: Minnesota Rules, part 2960.0080, subpart 4, items A and B.

Violation: The license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior.

All of the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours”, and the description of a “service hour” and other consequences that would be applied, were not indicated in writing to the resident in the Resident Handbook: Behavior and Corrective Action LASH 330 policy.

Additionally, the license holder’s Facility Rules and Due Process System and Consequence policies did not align with the current disciplinary/consequence policies and practices that were described through investigative interviews and that are outlined in the Resident Handbook and the Standard Operating Procedures for MnTC Staff.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the facility’s rules and due process system for residents meets all requirements. Within 30 days of receipt of this order, submit to DHS for approval:

· Revised policies and resident handbook that outlines which behaviors are acceptable and unacceptable, and what consequences will be applied. The consequences that will be applied need to be reasonable consequences.

Within 30 days of DHS approval, submit documentation demonstrating the following:

· All staff have been trained on all policies and procedures pertaining to discipline; and

· All youth have been provided verbal and written communication on which behaviors are acceptable and unacceptable, and what consequences will be applied.

3. Citation: Minnesota Rules, part 2960.0080, subpart 8, item A.

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

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of spirituality services meets all applicable requirements. Within 15 days receipt of this order, the license holder must contact DHS licensing to schedule a meeting to discuss and review the variance pertaining to required religious services.

If you fail to correct the violations 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 a corrective action ordered must be sent to DHS Licensing at:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Tina Christensen, Human Services Licensor

Licensing Division

Office of Inspector General

651-431-6610

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: Little Sand Lakeside

raw_content: April 13, 2022 Michelle Pepin, Authorized Agent Little Sand Group Homes 5910 Little Sand Lane NE Remer, MN 56672 License Numbers: 801412 Little Sand West 801413 Little Sand Lakeside 1092669 Little Sand East CORRECTION ORDER Dear Michelle Pepin: On March 7 through 9, 2022, a licensing review of the following programs 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 facilities under Minnesota Rules, parts 2960.0130 through 2960.0220 (Rule CRF): · Little Sand Lakeside located at 5908 Little Sand Lane NE, Remer, MN 56672 (801413) · Little Sand West located at 5910 Little Sand Lane NE, Remer, MN 56672 (801412) · Little Sand East located at 7274 Hwy 200 E, Remer, MN 56672 (1092669) As a result of the licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder. The following violations of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Throughout this Correction Order, the licensed programs will be referenced as follows: · Little Sand East (East) · Little Sand Lakeside (Lakeside) · Little Sand West (West) · When citation are specified to all licensed programs (All) Policy, Procedure and Practices 1. Citation: Minnesota Rules, part 2960.0160, subpart 1. Violation: The license holder did not develop admission criteria consistent with the statement of intended use. The admission criteria did not describe whether there are limitations about who the program will serve (All). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the admission criteria meets all applicable requirements. Within 30 days receipt of this order, submit revised admission criteria to demonstrate compliance. 2. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A. Violation: The outcome measures and program evaluation for calendar years 2020 and 2021 did not meet requirements in the following ways (All): a. The annual evaluation did not include accidents as a performance indicator; and b. The license holder did not annually evaluate the effectiveness of the facilities individual programs and use the information from the evaluations and program monitoring as a guide to improve program services in each individual license. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure outcome measures and program evaluations meets all applicable requirements. Resident Files Resident files reviewed are identified in the following manner: · Resident files numbered 1 through 3 (Lakeside) · Resident files numbered 4 through 6 (West) · Resident files numbered 7 and 8 (East) 6. Citation: Minnesota Rules, part 2960.0180, subpart 2, item B. Violation: Six of six resident files reviewed for requirements governing the individual treatment plan (resident files numbered 1, 3 through 5, 7 and 8) did not meet requirements. The treatment plan did not identify a schedule for accomplishing treatment goals and objectives. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements. Within 30 days receipt of this order, submit an individual treatment plan for one resident to demonstrate compliance (All). 7. Citation: Minnesota Rules, part 2960.0070, subpart 5, item A. Violation: One of six resident files reviewed for requirements governing resident admission screenings (resident file numbered 2) did not meet requirements. The vulnerability assessment was not completed accurately, intake information described specific details around the resident’s vulnerability that was not reflected in the screening. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident admission screenings and documentation meets all applicable requirements. Repeat Violation: This is a repeat violation. The license holder was cited for similar violations in the following orders: · May 20, 2020 · April 5, 2018 8. Citation: Minnesota Rules, part 2960.0080, subpart 11, Item D. Violation: Three of six resident files reviewed for requirements governing the safe storage and delivery of medicine (resident files numbered 1, 4 and 5) did not meet requirements. Residents were administered over the counter medications that were not resident specific and prescribed by a licensed prescriber. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all medications administered to residents are prescribed by a medically licensed person. Within 30 days receipt of this order, submit standing orders and administration records for one resident to demonstrate compliance (Lakeside and West). Repeat Violation: This is a repeat violation. The license holder was cited for similar violations in the following orders: · May 20, 2020 · April 5, 2018 9. Citation: Minnesota Rules, part 2960.0190, subpart 1, item A. Violation: Two of three resident files reviewed for requirements governing the transition services plan (resident files numbered 3 and 7) did not meet requirements. The plan did not identify resources available in the community to address the residents continuing needs after release from the facility. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the transition services plan meets all applicable requirements. Within 30 days receipt of this order, submit a transitions services plan for one resident to demonstrate compliance (Lakeside and East). If you fail to correct the violations 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 a corrective action ordered must be sent to DHS Licensing at: 1. By secure email to: heather.prior@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Heather Prior Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact Heather Prior, Human Services Licensor at 651-431-2694, as soon as possible. Heather Prior, MH/SUD/CRF 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/


facility_name: Little Sand West

summary: April 13, 2022 Michelle Pepin, Authorized Agent Little Sand Group Homes 5910 Little Sand Lane NE Remer, MN 56672 License Numbers: 801412 Little Sand West 801413 Little Sand Lakeside 1092669 Little San


facility_name: LSS Bethany Crisis Shelter

raw_content:
July 28, 2023

Jacob Margarit, Authorized Agent 2485 Como Ave.

Saint Paul, MN 55108

License Number: 800188 (CRF)

CORRECTION ORDER

Dear Jacob Margarit,

On June 6 and 7, 2023, the Department of Human Services (DHS) conducted a licensing review at your facility, LSS Bethany Crisis Shelter, located at  . 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 VIOLATIONS

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

PERSONNEL FILES

1. Violation: One of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 2). There was no documentation of orientation to operational policies and procedures.

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

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

2. Violation: One of two personnel files reviewed for requirements governing ongoing training did not meet requirements (personnel file numbered 3). A review of the emergency plan was not completed at least once every six months in 2022.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 13.

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

RESIDENT FILES

3. Violation: Three of three resident files reviewed for requirements governing resident admission documentation did not meet requirements. The resident file did not contain the following:

a. The language the resident writes (resident files numbered 1 through 3);

b. A description of the resident’s assets and strengths (resident files numbered 2 and 3); and

c. The spiritual or religious affiliation of the resident’s family (resident files numbered 1 through 3). 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 the completion of resident admission documentation meets all applicable requirements.

4. Violation: One of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident file numbered 2). There was no documentation to demonstrate that the resident was given a written copy of the resident’s basic rights information within 24 hours.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item A.

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

5. Violation: One resident files reviewed for requirements governing shelter discharge documentation did not meet requirements (resident file numbered 2). The resident file did not contain a transition services plan, and the resident remained in the shelter for more than 10 days.

Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item C and part 2960.0190, subpart 1, item A.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure shelter discharge documentation meets all applicable requirements.

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: LSS Life Haven

raw_content:
June 22, 2023

Jacob Thomas Margarit, Authorized Agent

LSS Life Haven

325 Jenks Ave

St. Paul, MN 55130

License Number 1020196 (CRF)

CORRECTION ORDER

Dear Jacob:

On April 11, 2023, a Department of Human Services (DHS) licensor conducted a licensing review at your facility located at 325 Jenks Ave, St. Paul 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 transitional services under Minnesota Rules, part 2960.0500. 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 FILES

1. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subpart 14 and 2960.0100, subpart 3, item A.

Violation: Three of three personnel files reviewed for requirements governing orientation did not meet requirements (personnel files numbered 1 through 3). There was no documentation of the following:

a. Training in general and special needs, including disability needs, of resident and families served;
b. Training for staff in all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services; and
c. The emergency plan was not reviewed with staff at least every six months.

Corrective Action Ordered: Immediately and on an ongoing basis, the license must ensure training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons numbered 1 through 3 have received training as identified above.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 3.

Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways:

a. There was no documentation that staff received annual training in vulnerable adult maltreatment reporting requirements (personnel files numbered 2 and 3); and
b. There was no documentation that staff received training in all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 through 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license must ensure training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons numbered 1 through 3 have received training as identified above.

RESIDENT FILES

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

Violation: Three of three resident files reviewed for requirements governing resident admission documentation did not meet requirements. The file did not contain the following:

a. The date and time of admission (resident files numbered 3);

b. The language the resident speaks and writes (resident files numbered 1 through 3);

c. A description of presenting safety concerns including assaultive behavior and victimization concerns (resident files numbered 2 and 3); and

d. The spiritual or religious affiliation of the resident and the resident’s family.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020.

4. Citation: Minnesota Rules, part 2960.0050, subpart 3, item B.

Violation: Two of three resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 2 and 3). The license holder failed to notify the resident’s parent, guardian, or custodian, within a reasonable time after admission to the facility that information on the resident’s basic rights was available.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident rights meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020.

5. Citation: Minnesota Statutes, sections 245A.65, subdivisions 1 and 2.

Violation: One resident file reviewed for requirements governing vulnerable adults did not meet requirements. The resident file did not contain documentation of the following:

a. Orientation to the internal and external vulnerable adult maltreatment reporting policies, (resident file numbered 1);
b. A statement of specific measures that will be taken to minimize the risk of abuse to that person when the individual assessment indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan (resident file numbered 1); and
c. Identified referrals made when the vulnerable adult was susceptible to abuse outside the scope or control of the licensed services.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure maltreatment of vulnerable adults meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated December 30, 2020.

If you fail to correct the violations 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 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/


facility_name: LSS Safe House

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


facility_name: MCF - Red Wing

report_date: September 8, 2023

raw_content:
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: 202300729

Date Issued: September 8, 2023

Name and Address of Facility Investigated:

Red Wing MCF
1079 Hwy 292
Red Wing, MN 55066

Disposition: Maltreatment determined as to physical abuse of the AV by the SP.

License Number and Program Type:

1036934-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas/Carla Harvieux

Minnesota Department of Human Services

Office of Inspector General, Licensing Division

PO Box 64242

Saint Paul, Minnesota 55164-0242

gessner.rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that on January 20, 2023, an alleged victim (AV) was in mechanical restraints (handcuffs) in the back of patrol car kicking the car door but stopped when a staff person (SP) directed the AV to stop. The SP then grabbed and pulled the AV out of the car, slamming the AV to the ground and rubbing the AV’s face into the road. The AV sustained injuries to her/his face, lip, and knee.

Date of Incident(s): January 20, 2023

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 23, paragraph (a):

"Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on February 8, 2023; from documentation at the facility; and through six interviews conducted with the AV, the SP, and facility staff persons (P1-P4).

The facility was a juvenile residential facility operated by the Department of Corrections (DOC), it had five living units and a secured unit which served as the facility’s intake and discipline unit. The facility offered residents numerous services, such as: counseling, academics, and vocational courses to prepare youth to re-enter the community. The AV was a resident at the facility for a non-violent offense.

The facility’s Response to Resistance, Restraint Systems, and Escape policy set forth definitions and guidelines for correctional staff persons on the response to resistance, the use of force, and restraints. The policy defined response to resistance as the “skillful use of tactics and techniques identified and approved by the DOC, intended to resolve a situation with the least amount of force that is reasonable under the totality of circumstances.” The policy defined reasonable force as “no reasonably effective alternative appears to exist and the response to resistance used is reasonable to effect the lawful purpose intended.” The policy stated that staff persons “must only use the least amount of force reasonable to control/resolve the situation,” and “make every reasonable effort to de-escalate a potential use-of-force situation…” Regarding the use of chemical irritants; the policy stated that chemical irritants were to be used before the application of physical force when practical and the watch commander and/or unit supervisor had to authorize its use, except in spontaneous situations where delay would result in bodily harm, death, or loss of control of an area or if the safety of staff persons and residents was in jeopardy.

The facility’s Juvenile Restrictive Procedures policy defined a device called the WRAP as “a safe restraint system, used to restrain a resident in an upright and seated position to maximize respiratory recovery and to escort a resident to disciplinary room time when the resident refuses to walk on the resident’s own accord, and designed to protect residents and staff [persons] by reducing the possibility of injury and death.” The policy further emphasized the need for staff persons to manage situations through de-escalation, and to treat residents humanely and respectfully during the use of restrictive procedures.

Information from the facility showed that on the evening of January 20, 2023, a resident at the Stanford cottage of the facility reported to a staff person that the AV had “hooch,” a homemade spirit. The SP, P3, and another staff person asked the AV to come out of her/his room. The AV refused and the facility’s Incident Command System (ICS: A system to request additional support from other staff persons) was activated at the request of the SP. The SP took out her/his chemical irritant and pointed it at the AV, who then became compliant. The SP and P3 applied handcuffs to the AV and the AV was escorted to a patrol car to transfer the AV to the Dayton Security Unit (DSU) for Disciplinary Room Time (DRT). What happened next was the focus of the report alleging that the SP used excessive force in removing the AV from the patrol car after kicking the rear driver’s side door of the car.

The AV provided the following information:

· The AV stated that as s/he was escorted out of the building to the car, s/he was handcuffed behind her/his back and was not resisting. Once inside the car, the AV kicked the rear driver’s side door about four times. The AV was seated sideways with her/his whole body on the backseat, feet towards the driver’s side and her/his head towards the passenger side. The AV stated that s/he kicked the door out of frustration because s/he was being sent to DSU and would not be able to visit with her/his mother that weekend. The AV stated that a staff person (the AV did not identify this staff person) opened the door and told her/him to stop kicking. The AV stated that s/he agreed and then went to the other side of the car because s/he saw staff persons surrounding the car.

· The AV stated s/he saw the SP shake up her/his chemical irritant and aim it at the car, the AV asked the SP if s/he was going to spray the AV, and the SP replied, “Yes.” The AV replied, “Over nothing, I’m not resisting anymore.”

· The AV stated that the SP reached in and grabbed her/him by her/his shirt collar on the right side and another unknown staff person grabbed the AV by the left side shirt collar and pulled her/him with “a lot of force,” and her/his “head flung out of the car and smack[ed] the pavement and they jumped on top of me and you know proceeded to restrain me.”

· The AV noted that when s/he had been restrained twice before, s/he would be asked many questions, given directions to follow but this time staff persons were quick to act. The AV noted that on previous occasions, staff persons would use a two or four point take down, but this time staff persons just grabbed her/him by the collar and flung her/him out of the car as hard as they could, hitting and skidding across the ground. The AV noted that the pavement outside of the Stanford cottage was icy and slushy.

· The AV stated that the SP applied pressure on her/his head and felt like her/his head was rubbed into the pavement. The AV noted that s/he tried to adjust her/his head so that it did not hurt as much but more force was applied as a result. The AV stated that s/he was told to stop resisting but said, “I’m not resisting what the fuck are you talking about?”

· While the AV was being restrained on the ground, the AV made threats against staff persons. The AV was then placed in a WRAP and then put back in the backseat of the car and driven to the DSU to be placed in a DRT room. Prior to being placed in DRT, the VA remained in the WRAP for approximately 30 minutes, while staff persons waited for the AV to calm down, the AV was periodically checked on by staff persons.

Note: Photographs taken of the AV shortly after the incident, showed a large abrasion to the AV’s right cheek below the eye with dark colored debris within and surrounding the site of that abrasion and the abrasions to the AV’s right knee. Photographs taken showed partial redness on the lower lip but could not be determined if that was because of the incident. When investigators met with the AV, the abrasion on the cheek still had remains of scab tissue.

P1 provided the following information:

· P1 arrived at Stanford cottage in response to the facility’s ICS system being activated. The SP and P3 were restraining the AV on the floor, face down in the hallway outside of the AV’s room. The SP and P3 handcuffed the AV, stood the AV up and walked her/him to the front door towards the patrol car. P1 stated that once they were outside, things changed. The SP yelled at the AV to get her/his feet in the car, the AV said they were, and the SP slammed the door shut.

· The AV began to kick the rear driver’s side door, swearing, and yelling at the SP; there was yelling back and forth between the SP, P3 and the AV. The SP asked for the WRAP, P1 stated s/he asked to de-escalate the situation, but the SP insisted on using the WRAP. The AV then stated, “I’m done kicking,” multiple times. The SP again asked for permission to the use the WRAP; permission was granted. The SP went to the rear passenger side, the SP and another staff person (P1 thought it was P3) grabbed the AV and in a “lightning quick” manner the AV went “real hard” face down onto the road.

· P1 stated that the SP had her/his hand on the AV’s head and the AV spat out a mouth full of busted up asphalt, some of which got on the SP. P1 stated that the AV’s “cheekbone was bleeding pretty good at that point.” P1 noted that the AV began to make threats against staff persons. P1 stated that staff persons heard threats all the time, such as, “I better not catch you on the outside.”

· P1 characterized the manner in which the AV was removed from the car as excessive because it was unnecessary and intense, and P1 had offered to try to de-escalate the situation. P1 thought that the SP and another staff person may have fallen on top on the AV when s/he was removed from the car. P1 retrieved the WRAP after the AV was removed from the car.

· P1 stated that de-escalation was part of the annual training staff persons received on restraints.

P2 provided the following information:

· P2 stated that when the AV kicked the door, the SP asked the AV to stop and took out her/his chemical irritant to get the AV to stop kicking the door. P2 stated that P1 offered to de-escalate the situation before P1 retrieved the WRAP.

· P2 stated that the SP reached in the car and grabbed the AV by the arm, pulled the AV out, and the AV hit the ground and the SP went down to the ground at the AV’s side. P2 recalled that s/he only saw the SP reach into the car and grab the AV. P2 stated s/he believed it was excessive but did not say anything because s/he felt uncomfortable speaking up amongst senior officers after the offer from P1 to de-escalate was ignored; the “mindset” was that the AV was going in the WRAP.

· P2 stated s/he assisted in restraining the AV by holding down the AV’s ankles while P3 secured the AV’s upper left body. P2 noted that while on the ground the AV did not attempt to kick or spit at any staff person.

P3 provided the following information:

· P3 recalled that the AV did not stop kicking the door when s/he was asked to stop so the SP requested permission to use the WRAP. P3 stated that s/he opened the rear passenger door and P2 helped the SP remove the AV from the car.

· P3 stated that s/he did not see how the AV was removed because s/he was looking down because it was slippery outside, but s/he did hear the AV hit the ground. P3 stated that the SP was on the right side of the AV and P2 got down to secure the AV’s left side, placed her/his hand on the AV’s shoulder and held the AV’s handcuffed hand.

· P3 stated that a staff person asked for a spit hood but it was not used.

The SP provided the following information:

· The SP stated that when the AV was placed in the car, s/he refused to put her/his feet in the car, so another staff person put her/his feet in, and the SP slammed the door shut.

· The SP stated that after the AV kicked the door another staff person (the SP did not recall who) called for the WRAP; it was approved. The SP noted that s/he took her/his chemical irritant out when the AV was kicking the door but the AV yelled and licked the window. P3 tried to open the rear driver’s side door but it would not open so the SP and P3 then went to the passenger’s side.

· The SP stated that the AV was sitting on the edge of the seat facing out with her/his feet facing the rear passenger side door. The SP stated s/he took the AV’s right arm and shoulder and took the AV to the ground. Once on the ground, the AV’s feet were towards the car. The SP stated that s/he could not recall if another staff person also reached in to remove the AV from the car, but it could have been P2.

· The SP said it took “little” effort to remove the AV from the car but noted that the AV was struggling and pulling away. The SP stated that once on the ground, the AV kept thrashing her/his head side-to-side while kicking her/his legs. The SP denied rubbing the AV’s face into the pavement or using excessive force and that s/he did not place her/his hand on the AV’s face, only on the AV’s right shoulder. The SP noticed the abrasion on the AV’s face when the AV was sat up after the WRAP was applied and stated the asphalt caused the abrasion. The SP stated that the AV spat at her/his general direction, so s/he called for a spit hood but it wasn’t used.

· The SP stated that s/he did not fall on top of the AV but did not know if another staff person did because s/he was not paying attention to what other staff persons were doing at the time. The SP took control of the AV’s right arm and P3 had the AV’s left while other staff persons put the AV into the WRAP and placed the AV back in the car. The SP noted s/he was not certain who or how many staff persons put the AV back in the backseat because s/he was walking around the front of the car to start it and the AV did not become compliant until s/he was in the WRAP cart at the DSU.

· The SP stated that the WRAP was used because the AV did not verbally comply when s/he was asked multiple times to stop kicking the door and once the other door was opened, the AV refused to get out of the car to place her/him in mechanical leg restraints.

· The SP stated that the AV was threatening staff persons. The SP stated that staff persons were threatened all the time. When asked if there was any training on how to handle threats from residents, the SP stated, “Just ignore them.” The SP stated that threats from residents was something “you get used to.”

· The SP did not recall any staff person offering to de-escalate the situation. The SP stated that staff persons tried de-escalating back in the cottage and again when the AV was asked to stop kicking the door.

Note: The SP’s personnel records showed that the SP had previously received a written reprimand for failing to attempt to de-escalate situations with residents.

P4 provided the following information:

· Throughout the period of the incident, P4 observed and relayed information back and forth to the watch commander.

· P4 stated that the SP and P3 asked the AV to stop kicking the door. P4 noted that the SP tried to de-escalate the situation by explaining to the AV what was going to happen. The SP directed P4 to ask permission to use the WRAP. P4 stated that the SP and possibly another staff person removed the AV the car but could not recall because “it was a bit of a blur when [the AV] was removed from the car.”

· P4 stated that s/he did not see the AV’s head hit the ground but once the AV was on the ground other staff persons descended on the AV. Once the AV was on the ground, the AV became combative by whipping her/his head, trying to kick, flailing, and making threats against staff persons. P4 noted that threats against staff persons were common.

· P4 stated that s/he had been involved in several incidents where a resident was placed in a WRAP and had never seen an abrasion on a resident’s face like the AV had, and most times when a resident was placed in a WRAP, it happened indoors.

P5 provided the following information:

· P5 reviewed reports submitted by staff persons and reviewed video footage from a security camera located about 100 yards from the location of the incident. The video was too grainy to show details but was sufficient to support concerns raised by staff persons about how the AV was taken out of the car and to the ground while handcuffed behind her/his back and the SP may have “overreacted.”

· De-escalation techniques involve reflective listening, explaining to the resident the pros and cons of resolving a situation peacefully, and lowering the overall tone of a situation.

Incident Reports filed by staff persons were inconsistent on whether or not another staff person assisted the SP in removing the AV from the car. The Incident Report filed by the SP only stated, “I took control of [AV’s] right side and escorted [her/him] out of the vehicle, placing [her/him] on the ground.”

The SP and P1-P5, were trained on the above policies and Reporting of Maltreatment of Minors Act.

Conclusion:

A. Maltreatment:

Information showed that while the AV was handcuffed behind her/his back and sitting in the back of a patrol car, s/he kicked the rear driver’s side door. The AV was directed to stop and complied. The SP asked for and was granted permission to use the WRAP. P1 offered to try to de-escalate the situation but got no response, this was corroborated by P2. The SP reached in and removed the AV, forcing the AV to the ground with excessive force causing the AV to sustain injuries to her/his face and knee.

There was inconsistent information from P1-P4 whether policy was followed and whether any other or which staff person assisted the SP in removing the AV from car. P1 and P2 believed the injuries could have been avoided if further de-escalation had been attempted but that the “mindset” was that the AV was going in the WRAP. The SP and P1-P4 each noted that verbal threats from residents were common and typically ignored. There was no information that throughout the incident the AV physically attempted to kick or spit on any staff persons.

Given the testimony provided through interviews with staff persons and the facility’s requirement per policy to de-escalate a potential use-of-force situation, to use the least amount of force reasonable, the physical injuries sustained by the AV, and staff persons belief that the SP used excessive force or overreacted there was a preponderance of the evidence that the SP’s conduct was not accidental and caused the AV physical injury.

It was determined that physical abuse occurred (any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury).

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.

The SP was trained on the facility’s relevant policies and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was responsible for the 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 physical abuse for which the SP was responsible was not recurring maltreatment because it was a single incident but did meet the statutory criteria to be determined as serious maltreatment because the AV sustained an injury resulting in a large abrasion to the AV’s right cheek and small abrasions to the right knee. The SP was disqualified from providing direct contact services.

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:

Pursuant to policy, the facility conducted an administrative review of the incident and determined there was support for concerns raised by staff persons about how the AV was taken to the ground while handcuffed behind her/his back. The facility reported the incident to the DOC’s Office of Professional Accountability and DHS.

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

The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.

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


raw_content:
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: 202300510

Date Issued: April 26, 2023

Name and Address of Facility Investigated:

MCF-Red Wing
1079 Highway 292
Red Wing, MN 55066

Disposition: Maltreatment determined as to neglect of an alleged victim by a staff person.

License Number and Program Type:

1036934-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

Carla Harvieux
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
carla.harvieux@state.mn.us

651-431-6616

Suspected Maltreatment Reported:

It was reported that a staff person (SP) had a romantic relationship with an alleged victim (AV), who was 17 years old at the time s/he was at the facility.

Date of Incident(s): Prior to January 17, 2023

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 20; and subdivision 15, paragraph (a), clauses (1) and (2):

"Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.

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 January 26, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1 and P2). This investigator met the AV, but s/he declined to complete an interview with this investigator. However, the AV provided information to P1 regarding the allegations. Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters.

The facility was a juvenile residential facility operated by the Minnesota Department Corrections that focused on encouraging the development of healthy living and social skills to prepare youths to re-enter the community. The facility had a video recording system that recorded common areas of the facility and most areas on the facility grounds.

The AV was admitted to the facility as a condition of probation; s/he had past convictions for first degree aggravated robbery, had other pending charges, and did not attend school regularly. The AV was 17 years old when the incidents with the SP occurred and his/her diagnoses included other specified trauma and stressor related disorder, attention deficit hyperactivity disorder, combined presentation, oppositional defiant conduct, and unspecified psychosis, likely related to insomnia and trauma. The SP was six years older than the AV.

Facility documentation and information from P1 and P2 (a supervisory staff person) showed the following:

P1 said that the facility became aware of concerns regarding inappropriate boundaries between the SP and AV, then reviewed video recordings of interactions between them and began an internal investigation into the concerns. Several youths who did not want to be considered “snitches,” provided information to P1 that the AV and SP told each other, “I love you,” and discussed “hooking up” after the AV was discharged from the facility. In addition, the SP brought the AV potato chips, snack crackers, allowed the AV to make “extra” telephone calls, and walked with the VA and sat by him/her more often than with other youths. The SP also went with the AV when the AV took out the garbage after dark but did not accompany other youths when they took the garbage out.

P1 reviewed recordings made by the facility’s video recording system and provided them to this investigator. The recordings showed that on December 8, 2022, the SP and AV were walking with a group of youths between two buildings on the facility grounds. The SP and AV walked a few feet behind the group, which twice caused the group to pause and wait for the SP and VA to catch up. There were video recordings of incidents not related to alleged maltreatment or the allegations in this report that showed the SP engaged in conduct which violated the facility’s policies and procedures. P1 and P2 took spoke with the SP regarding those concerns and they were not investigated in this report.

The AV denied that s/he and the SP “touched” each other in a sexual manner. However, the AV acknowledged that there were times when s/he and the SP were physically close to each other and that they had agreed to contact each other via social media after the AV was discharged from the facility. The SP also permitted the AV to remain in common areas of the facility when the AV should have been in his/her bedroom when the AV had “good behavior,” but s/he was unable to define what good behavior was. The AV did not plan to be significant others with the SP, but s/he wanted to attempt to have a sexual relationship with the SP after the AV was discharged.

The SP did not complete an interview with this investigator, but when the SP spoke with P1, s/he said that on unspecified dates s/he gave personal food items to the AV and told the AV personal information about his/her history. The SP understood that his/her actions might be viewed as favoritism or being too close to a youth. However, the SP denied that s/he and the AV told each other they loved each other and denied that s/he planned to have a relationship with the AV upon his/her discharge from the facility.

The facility’s Personal Association between Staff and Offenders policy stated that staff persons were not to have contact with youths who currently or formerly received services at the facility other than contacts required by departmental work assignments.

Giving or accepting gifts, articles, special favors (including food) to youths or their families was also not allowed. Employees who failed to report personal associations might be disciplined up to and including discharge from employment.

The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the facility’s policies and procedures and on the Maltreatment of Minors Act prior to the incident. On

October 14, 2022, the SP had a “Supervisory Conference” in which s/he and his/her supervisor discussed concerns that the SP did not treat the youths equally at the facility.

Conclusion:

A. Maltreatment:

Several youths provided consistent information to P1 that the SP and AV said that they loved each other and discussed “hooking up.” In addition, the SP gave the AV preferential treatment when s/he brought the AV snacks, allowed him/her to make additional phone calls, remain in common areas when s/he should be in his/her bedroom, and sat/walked with the AV more often than with other youths.

According to the AV, s/he and the SP did not have sexual contact, but they were physically close to each other at times, and had agreed to connect via social media after the AV was discharged. The AV acknowledged that the SP let the AV remain in common areas of the facility when s/he should have been in his/her bedroom and the AV wanted to try to have a sexual relationship with the SP.

The SP provided information to P1 showing that s/he gave personal food items to the AV and told the AV personal information about his/her history. The SP knew that his/her actions might be considered as favoritism, but s/he denied that s/he and the AV told each other they loved each other and denied that s/he planned to have a relationship with the AV upon his/her discharge from the facility.

Information was consistent that the SP did not follow the facility’s policies and procedures in his/her interactions with the AV and a video showed the SP walking with the AV behind a group, so the group had to wait for the SP and AV to catch up.

Although there were concerns that the SP had a romantic relationship with the AV, given that no information showed that the SP had sexual contact with the AV, there was not a preponderance of the evidence that the SP had sexual contact with the AV.

It was not determined that sexual abuse occurred ("sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse).

Although the SP denied that s/he and the AV told each other they loved each other and denied that s/he planned to have a relationship with the AV upon his/her discharge from the facility, the SP had reason to minimize his/her actions for fear of consequences and several youths provided consistent information that this occurred.

In addition, the SP gave the AV preferential treatment when s/he brought the AV snacks, allowed him/her to make additional phone calls, remain in common areas when s/he should be in his/her bedroom, and sat/walked with the AV more often than with other youths.

The facility encouraged the development of healthy living and social skills to prepare youths to re-enter the community. The AV needed supports to develop and maintain necessary life and social skills, including assistance to successfully complete high school and to access appropriate care from community mental health care professionals.

The AV, who was 17 years old when the incidents occurred, thought s/he would have future social interaction with the SP, who was 6 years older than the AV, after s/he left the facility, so it was likely that the AV’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other attempts to provide him/her with therapeutic services, now and in the future, was hindered. Therefore, there was a preponderance of the evidence the SP’s interactions with the AV were detrimental to the AV’s ongoing mental health which was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endanger the AV’s physical or mental health when reasonably able to do so.

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.

The SP was trained on the Reporting of Maltreatment of Minors Act and the facilities policies and procedures. The SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring because the SP’s pattern of behavior was considered a single incident. The maltreatment for which the SP was responsible was not serious because the AV did not sustain a serious injury as defined by statute from the maltreatment.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph © 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 was licensed by the Department of Corrections and was not required to complete an Internal Review. On December 16, 2022, the SP’s employment at the facility ended.

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

The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.

Because this facility was licensed by the Minnesota Department of Corrections, a copy of this report was sent to them to address any policy violations identified in this report.

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/


facility_name: Naima House

raw_content:
August 29, 2024

Carmeann Foster, Authorized Agent

Rebound Inc

6120 Earle Brown Drive #230

Brooklyn Center, MN 55430

License Number: 1090428

Report Number: 202406447

CORRECTION ORDER

Dear Carmeann Foster:

On August 20, 2024, a Department of Human Services (DHS) licensor conducted a licensing investigation at your facility, Naima House located at 1017 Humboldt Avenue North, Minneapolis, MN, 55411. This investigation 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; children’s group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220; 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 did not meet licensing rules and statutes, as described below.

Physical Plant and Practice

1. Violation: The license holder’s practice did not ensure adequate facilities for services. Four of six beds had what appeared to be urine and/or blood stains on bed linens and/or mattresses. The license holder’s practice did not ensure residents’ (resident files numbered 1 and 2) right to clean and safe surroundings.

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 1, item H; and 2960.0110, subpart 3, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure adequate facilities for services and resident rights meet all applicable requirements. Immediately the license holder must provide clean, stain free, linens and mattresses to current residents and within 14 days of receipt of this order, submit documentation all beds and linens demonstrate compliance.

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 ginny.benson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Ginny Benson

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 violation(s). 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 651-431-6957or at ginny.benson@state.mn.us

Sincerely,

Ginny Benson, 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/