facility_name: Itaskin Treatment Center

raw_content:
August 25, 2025

Heidi Seaton, Authorized Agent

North Homes, Inc

303 SE 1st St

Grand rapids, MN, 55744

License Numbers: 1010657 (CRF – Itaskin Treatment Center)

1047010 (CRF – North Homes Cottage)

CORRECTION ORDER

Dear Heidi Seaton:

On June 9 through 12, 2025, DHS licensors conducted a licensing review of Itaskin Treatment Center, located at 1880 River Rd, Grand Rapids, MN, 55744, and North Homes Cottage, located at 1920 SE River Rd, Grand Rapids, MN, 55744. This review was conducted to determine compliance with state and federal laws governing children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0220, shelter care services for children under Minnesota Rules, part 2960.0510 through 2960.0530, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, restrictive techniques standards under Minnesota Rules, part 2960.0710, and qualified residential treatment programs under Minnesota Statutes, section 245A.25. 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.

Throughout this order, the licensed programs will be referenced as follows:

· Itaskin Treatment Center (ITC);

· North Homes Cottage (NHC); and

· When citations are specific to both licensed programs (ALL).

Procedures

1. Violation: The license holder’s grievance procedure did not meet requirements (ALL). The procedure did not require that a person filing a grievance would receive a response within five days. The procedure included multiple steps by which a grievance would be reviewed, and the first step did not include a timeframe.

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

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

Practices

2. Violation: The license holder’s program evaluation for 2023 and 2024 did not meet requirements in the following ways (ALL):

a. The evaluation of strengths and weaknesses did not include the following required performance indicators:

i. Accidents; and

ii. Information from Minnesota Rules, part 2960.0060, subparts 1 and 2, regarding the program’s outcome measures; and

b. Documentation did not include an evaluation of the program’s strengths and weaknesses based on results of resident and family satisfaction surveys.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program evaluations include all required components.

3. Violation: Two of two weeks of documentation reviewed for requirements governing clinical supervision did not meet requirements. All staff providing program services did not receive weekly face-to-face clinical supervision:

a. For the treatment week beginning June 1, 2025: Three staff persons (NHC); and One staff person (ITC); and

b. For the treatment week beginning December 15, 2025: One staff person (ALL).

[Rule/Statute] Violated: Minnesota Rules, part 2960.0630, subpart 2

Repeat Violation: In a Correction Order that DHS issued on December 3, 2021, you were previously found in violation of this same rule.

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

Resident Files

Resident files reviewed are identified in the following manner:

o Resident files numbered 1 through 5, and 7 (NHC);

o Resident files numbered 2 through 4, 6 and 7 (ITC).

4. Violation: One of six resident files reviewed for requirements governing the license holder’s ability to meet residents' needs did not meet requirements (resident file numbered 2). There was no documentation to demonstrate the license holder determined the program could meet the resident’s cultural, emotional, educational, mental health and physical needs.

Rule Violated: Minnesota Rules, part 2960.0160, subpart 2, item C

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

5. Violation: Six of seven resident files reviewed for resident screenings did not meet requirements in the following ways:

a. For a shelter admission, there was no documentation to demonstrate a health screening was arranged for within 24 hours of admission (resident file numbered 2);

b. The health screening did not include all required components. Documentation did not identify the resident’s most recent clinic name, address, and telephone number (resident files numbered 1 through 5 and 7); and

c. The cultural screening was not completed, it was blank (resident file numbered 7).

Rule Violated: Minnesota Rules, parts 2960.0520, subpart 2, item B, and 2960.0070, subpart 5, items B and C.

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

6. Violation: Three of seven resident files reviewed for requirements governing admission procedures did not meet requirements. There was no documentation to demonstrate the license holder provided the following required information:

a. The facility’s rules and details of the due process system used in the facility, verbally and in writing to the resident (resident files numbered 2 and 5);

b. A written copy of the resident’s basic rights information (resident files numbered 2 and 5);

c. That information on the resident’s basic rights is available, to the resident’s parent, guardian or custodian (resident files numbered 2, 4, and 5); and

d. How to contact the appropriate state-appointed ombudsman (resident files numbered 2 and 5); and

e. A copy of facility rules (resident file numbered 2).

Rule Violated: Minnesota Rules, parts 2960.0160, subpart 4; 2960.0080, subpart 4; and 2960.0050, subpart 3, items A, B, and E

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

7. Violation: Six of six resident files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways:

a. The ITP was not completed within 10 working days of admission, it was completed late (resident files numbered 1 and 4);

b. The ITP did not include a schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 4, 6 and 7);

c. The ITP did not include all goals and objectives of treatment (resident file numbered 7). Documentation in the resident file indicated the license holder provided family therapy, and there was no related goal or objective in the ITP; and

d. The ITP did not include the use of all psychotropic medications (resident files numbered 2 and 4).

Rule Violated: Minnesota Rules, part 2960.0600, item A and part 2960.0620, subpart 1, item A

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

8. Violation: One resident file reviewed for requirements governing family involvement in a qualified residential treatment program (QRTP) did not meet requirements (resident file numbered 6). There was no documentation to demonstrate how the program maintains the youth’s connections to their siblings.

Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (h)

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

9. Violation: Four of four resident files reviewed for requirements governing the review of the resident’s case and treatment plans did not meet requirements (resident files numbered 2, 3, 6 and 7). There was no documentation to demonstrate the plan was reviewed on a monthly basis.

Rule Violated: Minnesota Rules, part 2960.0180, subpart 2, item B

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of the treatment plan review meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating a monthly review took place.

10. Violation: Three of five resident files reviewed for requirements governing psychotropic medications did not meet requirements. There was no documentation to demonstrate the following was completed as required:

a. Monitoring for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication (resident files numbered 3, 4 and 7); and

b. Monitoring for tardive dyskinesia at least every three months if the resident is prescribed antipsychotic medication (resident files numbered 3 and 7).

Rule Violated: Minnesota Rules, part 2960.0620, subparts 2 and 3

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

11. Violation: One resident file reviewed for requirements governing time-out did not meet requirements (resident file numbered 7). Discharge documentation identified the use of time-out occurred on November 30, 2024, and there was no documentation of the time-out that included the factors or circumstances which caused the need for the use of time-out, the resident’s response, their ability to de-escalate during the time-out or their ability to maintain acceptable behavior after the time-out.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of the use of time-out meets all applicable requirements.

12. Violation: One of three resident files reviewed for requirements governing restrictive procedures did not meet requirements (resident file numbered 7). The license holder documented the use of physical holds in a “Restrictive Procedure Report”. Documentation in the resident file referenced multiple instances of physical holds and physical escorts between June 24, 2024, and August 2, 2024, and there were no corresponding “Restrictive Procedure Reports” in the resident file.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, item K.

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

13. Violation: Five of five resident files reviewed for requirements governing the administrative review of the use of restrictive procedures did not meet requirements in the following ways:

a. The administrative review was not completed within three working days for the following instances of restrictive procedures:

i. March 31 and April 6, 2025 (resident file numbered 5); and

ii. August 29, October 28, November 26 and 27, 2024 (resident file numbered 7); and

b. The administrative review did not include whether the rule standards governing the use of restrictive procedures were met (resident files numbered 1, 3 through 5, and 7).

Rule Violated: Minnesota Rules, part 2960.0710, subpart 10, item C.

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

14. Violation: Six of six resident files reviewed for requirements governing transition services plans did not meet requirements (resident files numbered 1, 2, and 4 through 7). Documentation did not demonstrate a copy of the plan was given to the resident.

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

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

15. Violation: Two of three resident files reviewed for requirements governing the provision of aftercare in a qualified residential treatment program (QRTP) did not meet requirements (resident files numbered 2 and 7). There was no documentation to demonstrate the license holder provided discharge planning and family-based aftercare support to each youth for at least six months after discharge.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (i).

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

Personnel Files

Personnel files are identified as follows:

o Personnel files numbered 1 through 15 (ALL)

16. Violation: Two of six personnel files reviewed for requirements governing documentation of staff qualifications did not meet requirements (personnel files numbered 3 and 4). The personnel file did not include records showing that the staff person’s professional licensure is current.

Rule Violated: Minnesota Rules, part 2960.0150, subpart 2

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

17. Violation: Nine of nine personnel files reviewed for requirements governing annual training did not meet requirements in the following ways:

a. There was no documentation to demonstrate the staff person received annual training on the program abuse prevention plan (PAPP) in 2024 (personnel files numbered 1, 3, 4, 6, 7, and 9 through 11); and

b. There was no documentation to demonstrate the license holder reviewed the emergency plan with the staff person at least once every six months (personnel file numbered 12).

Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, part 2960.0080, subpart 14

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

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 Alyssa.nelson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Alyssa Nelson

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 in writing. Your request must:

1. Specify the parts of the correction order that are alleged to be in error;

2. Explain why they are in error; and

3. Include documentation to support the allegation of error.

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. 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 or at katie.a.leuer@state.mn.us

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/


state: MN

report_date: February 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: 202207592

Date Issued: February 8, 2023

Name and Address of Facility Investigated:

Itaskin Treatment Center
1880 River RD
Grand Rapids, MN 55744

Disposition:

Allegation One: Maltreatment not determined

Allegation Two: Maltreatment determined

License Number and Program Type:

1010657-CRF (Children’s Residential Facility)

Investigator(s):

Carla Harvieux
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6616

Suspected Maltreatment Reported:

Allegation One: It was reported that a staff person (SP) pushed an alleged victim (AV1) to the ground during a kickball game at the facility causing AV1 rib pain.

Allegation Two: It was reported that the SP pushed an alleged victim (AV2) onto AV2’s bed and held him/her by the back of the neck.

Date of Incident(s): September 14, 2022

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and 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 October 10, 2022; from documentation at the facility, records from a law enforcement agency, and AV2’s medical records; and through six interviews conducted with facility staff persons (P1, P2, P3, and the SP), AV1, and AV2, and information in the Internal Review provided by a child (C) who resided at the facility.

The facility provided comprehensive evaluations to children 11-18 years of age in a therapeutic setting and made specific treatment recommendations for each child to meet the child’s individual needs. Children who resided at the facility might be there because they needed personal/family crisis protection, had run away, had high risk or self-injurious behaviors, or needed respite care. At the facility, children received various assistance including mental health treatment, family assessment, trauma focused care, chemical dependency education, on site schooling, dialectical behavioral therapy, medical management, or other services as needed.

Facility documentation, records from a law enforcement agency, medical records, information provided by the AVs, the C, P1, P2, P3, and the SP in interviews with this investigator; and information from facility’s Internal Review, provided the following information:

Allegation One: It was reported that the SP pushed AV1 to the ground during a kickball game at the facility causing AV1 rib pain.

AV1 said that on the date of the incident, s/he and other unspecified children played kickball with the SP on the grounds of the facility. AV1 thought that the SP was “cheating” at the game because the SP would not let AV1 kick the ball again, so AV1 picked up a “stick” and approached the SP with it, but did not make contact with the SP. When AV1 neared the SP, AV1 used an expletive toward the SP, who then “shoved” AV1 on his/her right side, which caused AV1 to fall to the ground.

P1 said that s/he was playing a game of kickball with the SP, AV1, and other children on the date of the incident. When it was AV1’s turn to kick, s/he kicked the ball, but slipped on loose sand and fell. The SP and some of the children laughed at AV1 and s/he became upset. AV1 stated that s/he was “done” playing and walked away from the game followed by P1, but when AV1 reached the facility entrance, s/he turned, picked up a “sharp stick,” ran toward the SP with the stick in his/her hand, and attempted to stab the SP. The SP dodged AV1 then shoved AV1 to the ground with his/her palm, hitting AV1 on his/her right upper shoulder/chest. AV1 fell to the ground, gasped for air, cried, and screamed that his/her ribs hurt. AV1 then stood and walked away from the SP, and P1 followed him/her, guiding AV1 into the facility. P1 assessed AV1 for injuries but did not see any, but since AV1 said that s/he had pain near his/her right ribs, P1 asked a facility health care professional (HCP) to assess AV1 for injuries. P1 thought that the SP was attempting to prevent AV1 from harming the SP and said that the SP’s actions seemed to be a more of a reaction.

Documentation showed that the HCP observed no injuries to AV1, but AV1 had a few bruises on his/her left side that appeared to be a few days old. AV1 told the HCP that s/he had no pain.

The SP said that when s/he was pitching the ball during the kickball game, AV1 screamed at the SP that s/he was going to “fuck” him/her up, and called the SP a “cheating piece of shit.” The SP turned toward AV1, who was not initially in the SP’s line of sight, and saw AV1 running toward the SP with a stick raised in the air. The SP was startled and attempted to move aside, but AV1 ran into the SP, hit the SP’s hand with the stick, and fell onto the ground, landing on his/her bottom. AV1 stood and yelled at the SP, so the SP backed away from AV1. P1 then redirected AV1 and walked inside the facility with him/her. The SP ended the kickball game, walked inside the facility with the youths, and told P2 what happened during the game. P2 told the SP to leave the facility for the day, because someone told P2 that the SP pushed AV1. The incident occurred very quickly and the SP reacted when s/he saw AV1 coming toward him/her with the stick. The SP was unable to describe the size of the stick, but denied that s/he pushed AV1 and immediately left the facility when P2 told him/her to go.

P2 and P3 provided consistent information that pushing a child to the ground was not a permitted action at the facility. P2 and P3 contacted the SP to gather information to complete the Internal Review for this incident but the SP did not respond to them.

The facility’s Policy and Procedure Manual stated that staff persons were prohibited from using corporal punishment including rough handling, shoving, ear or hair pulling, shaking, slapping, kicking, biting, pinching, throwing objects at children, or spanking them.

Restrictive procedures were approved for use by certified staff persons included physical escorts or physical holds in emergency situations as a response to imminent danger to residents or when less restrictive interventions were ineffective.

The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Maltreatment of Minors Act prior to the incident and on the AVs’ plans. The SP was most recently trained on the facility’s policies and procedures on April 4, 2022.

Conclusion for Allegation One:

Information was consistent that on September 14, 2022, the SP, P1, AV1, and several unidentified children participated in a kickball game at the facility. AV1 said that s/he thought the SP was “cheating” at the game and s/he ran toward the SP with a stick but did not hit the SP with it.

The SP said that AV1 used threatening language to him/her, ran at the SP with a stick, startled the SP, and hit the SP’s hand with the stick. The SP attempted to step aside, but AV1 ran into the SP and fell onto his/her bottom. P1 assisted AV1 to enter the facility, the SP ended the kickball game, and P2 told the SP to leave the facility for the day, because someone told P2 that the SP pushed AV1.

P1 witnessed the incident and observed the SP shove AV1 to the ground but thought that the SP’s actions were more of a reaction. AV1 gasped for air when s/he fell, cried, and said that his/her ribs hurt, so P1 asked the HCP to assess AV1. The HCP documented that AV1 had no injuries and told the HCP that s/he had no pain.

Although the SP stated that AV1 “ran into” the SP when the SP was startled and tried to move out of AV1’s way causing AV1 to fall, AV1 and P1 each stated that the SP “shoved” AV1 to the ground. However, given that P1 stated the SP’s actions were reactionary, that AV1’s behavior was aggressive at the time of the incident, and that AV1 was not injured, there was not a preponderance of the evidence that the SP’s actions caused injury or represented substantial risk of physical injury to AV1.

It was not determined that physical abuse of AV1 occurred ("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).

Allegation Two: It was reported that the SP pushed AV2 onto AV2’s bed and held him/her by the back of the neck.

AV2 was admitted to the facility on September 13, 2022, and on September 14, 2022, the SP assisted him/her to wash some of his/her laundry at the facility. The SP asked AV2 to remove a string tie from the waist band of his/her shorts because children at the facility could not wear clothing items with strings/ties. AV2 did not want to remove the string tie from the shorts and did not immediately respond to the SP’s request. An argument between the SP and AV2 began, and the SP attempted to take the string from AV2’s shorts, pushed AV2 face down onto his/her bed, and held AV2 by the back of his/her neck and squeezed for about ten seconds.

The C stated that s/he witnessed the incident between AV2 and the SP. The SP had AV2 “by the back of the neck, pinned down to the bed,” so the C called out for assistance from P2. When the SP heard the C call for P2, the SP released AV2.

P2 heard the C call, and immediately went to AV2’s bedroom where s/he assessed AV2 for injuries but did not observe marks on AV2’s neck. However, P2 asked the HCP to assess AV2.

The HCP documented that AV2 had no bruises or marks on his/her skin, had full range of motion, and reported mild pain when s/he bent his/her neck. AV2 was offered a warm/cold pack, but s/he declined. The HCP instructed AV2 to contact a staff person or the HCP if s/he had worsening pain. No information showed whether AV2 was assessed for injuries after the date of the incident. However, on September 16, 2022, AV2 said s/he had neck pain and was evaluated by a community health care professional who diagnosed AV2 with a soft tissue bruise, according to documentation completed by the HCP.

Medical records for AV2 showed that on September 16, 2022, s/he was evaluated at the emergency department of a hospital for neck pain. AV2 told hospital employees that an unspecified facility staff person attempted to place him/her in a hold two days earlier. AV2 initially had no pain, but now, his/her neck hurt. AV2 denied that s/he had difficulty breathing and had normal range of motion, but there were undescribed “signs of injury and trauma” present with muscular tenderness. AV2 was diagnosed with a bruise on his/her neck and instructed to use acetaminophen and ibuprofen for pain relief, then discharged back to the facility.

The SP said that s/he had been involved in holding youths at the facility several times but did not recall asking AV2 for a string from his/her shorts or holding AV2 on the date of the incident. The SP denied that s/he pushed AV2 onto his/her bed or held AV2 by the neck on his/her bed. The SP said that youths had hit him/her many times in the face and on his/her body during the time s/he worked at the facility but it was part of the job. The SP thought that s/he followed facility policies and procedures and said that the facility did not give him/her information regarding the allegations investigated in this report.

Records from a law enforcement agency showed that the agency investigated the September 14, 2022, incident between the SP and AV2. AV2 told a law enforcement officer (LEO) that the SP argued with AV2 regarding removing a string from AV2’s shorts, then placed both hands on AV2’s neck and squeezed for about ten seconds, then let go. The SP told the LEO that children at the facility were not permitted to wear clothing with strings/ties for safety reasons and that s/he went to AV2’s bedroom on the date of the incident to remove a string tie from AV2’s shorts. AV2 then swore at the SP, and punched, hit, and kicked the SP to get the string tie from the SP. The SP put AV2 in a “safety hold” by holding AV2’s hands behind his/her back to prevent AV2 from punching him/her until AV2 calmed. The SP said that the incident lasted about 20 seconds and denied that s/he had other physical contact with AV2. The law enforcement agency completed its investigation and took no further action.

P1 and P2 provided consistent information that the SP was contacted regarding this incident to complete the Internal Review, but s/he did not respond to attempts to reach him/her. No information showed that AV2 was using the string/tie in his/her shorts with the intention of harming him/herself or others at the time of the incident.

The facility’s Policy and Procedure Manual stated that staff persons were prohibited from using corporal punishment including rough handling, shoving, ear or hair pulling, shaking, slapping, kicking, biting, pinching, throwing objects at children, or spanking them.

Restrictive procedures were approved for use by certified staff persons included physical escorts or physical holds in emergency situations as a response to imminent danger to residents or when less restrictive interventions were ineffective. Holding a resident by the back of the neck on a bed was not an approved technique.

The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Maltreatment of Minors Act prior to the incident and on the AVs’ plans. The SP was most recently trained on the facility’s policies and procedures on April 4, 2022.

Relevant Rules:

Minnesota Rules, chapter 2960.0050, subpart 2, item E states that a resident has the basic right to be free from abuse, neglect inhumane treatment, and sexual exploitation.

Minnesota Rules, chapter 2960.0050, subpart 2, item R states that a resident has the basic right be free from restraint or seclusion used for a purpose other than to protect the resident from imminent danger to self or others, except for the use of disciplinary room time as it is allowed in the correctional facility's discipline plan.

Conclusion for Allegation Two:

A. Maltreatment:

AV2 provided consistent information to the law enforcement agency and this investigator that the SP placed his/her hands on AV2’s neck and held him/her on September 14, 2022.

The C said that s/he witnessed the SP hold AV2 by the back of the neck on his/her bed, and called for P2, who responded immediately. P2 did not see the incident but asked the HCP to assess AV2 for injuries. The HCP documented that AV2 had no injuries and had full range of motion, but had mild neck pain and was offered a hot/cold pack. Two days later, AV2’s neck pain continued and s/he was evaluated at the emergency department of a hospital. AV2 had a bruise on his/her neck and s/he was instructed to use over the counter pain relievers.

The SP told this investigator that s/he did not push AV2 onto his/her bed and hold him/her, however according to the law enforcement agency’s records, the SP provided conflicting information and stated that s/he put AV2 in a “safety hold” by holding AV2’s hands behind his/her back until AV2 calmed while the SP obtained a string/tie from AV2’s shorts.

Although the SP told this investigator that s/he did not hold AV2 and told the LEO that s/he held AV2’s hands, not his/her neck, given that the SP had reason to minimize his/her actions, that AV2 and the C provided corroborating information that the SP held AV2 by the back of his/her neck, and that AV2 had a bruise on his/her neck, AV2’s and the C’s account of the incident was more credible.

Holding a child by the back of the neck was against facility policies and procedures, not accidental or therapeutic conduct, inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and a violation of Minnesota Rules, chapter 2960.0050, subpart 2, item E and Minnesota Rules, chapter 2960.0050, subpart 2, item R.

Therefore, there was a preponderance of the evidence that the SP’s actions caused an injury to AV2 and represented a substantial risk of physical injury.

It was determined that physical abuse occurred ("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).

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 responsible for the care and supervision of AV2 when the incident occurred and was trained on the facility’s policies and procedures on April 4, 2022. The SP was responsible for the maltreatment of AV2.

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 because it was a single incident. The substantiated physical abuse for which the SP was responsible was serious because AV2 sustained a bruise to his/her neck during the incident.

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

Action Taken by Facility:

The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed by the SP. When this report was written, the SP was no longer employed at the facility.

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

Given that the facility took immediate corrective action, the facility was not issued a correction order for the violation outlined in this report.

The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is 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: 202200877 Date Issued: April 27, 2022 Name and Address of Facility Investigated: I.T.A.S.K.I.N Juvenile Center 1880 River Road Grand Rapids, MN 55744 Disposition: Maltreatment determined as to physical abuse of an alleged victim by a staff person. License Number and Program Type: 1010657-CRF (Children’s Residential Facility) Investigator(s): Carla Harvieux Minnesota Department of Human Services Office of Inspector General Licensing Division PO Box 64242 Saint Paul, Minnesota 55164-0242 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) called an alleged victim (AV) a “big dumb bitch,” but apologized later. The next day, the SP placed the AV in a restraint, threw the AV in the snow, blocked the AV in his/her bedroom, and slapped the AV’s face. Date of Incident(s): Prior to January 29, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and 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 March 9, 2022; from documentation at the facility; and through interviews conducted with facility staff persons (P1 and P2) and the AV. Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters. Attempts were also made to contact the SP via telephone and email. The facility provided comprehensive evaluations to children 11-18 years of age in a therapeutic setting and made specific treatment recommendations for each child to meet the child’s individual needs. Children who resided at the facility might be there because they needed personal/family crisis protection, had run away, had high risk or self-injurious behaviors, or needed respite care. At the facility, children received various assistance including mental health treatment, family assessment, trauma focused care, chemical dependency education, on site schooling, dialectical behavioral therapy, medical management, or other services as needed. Facility documentation showed that the AV’s diagnoses included major depressive disorder and unspecified disruptive impulse control and conduct disorder. The AV might be physically or verbally abusive to others when s/he was upset, and staff persons were to monitor his/her interactions with others. If the AV became frustrated or escalated his/her behavior, staff persons were to redirect him/her to take a break. If the AV was an immediate threat to him/herself or others, staff persons could restrain the AV, beginning with the least restrictive restraint as permitted by the facility’s Handle With Care training, but were required to end the restraint when the risk was reduced. Facility documentation, information provided by P1, P2, and the AV in interviews with this investigator, and information provided by the SP in the facility’s Internal Review, provided the following information · The AV said that on the evening of January 29, 2022, s/he was outside the facility without permission talking with other children through a window of their bedroom. Staff persons inside the facility asked the AV to come inside, but s/he declined and continued talking with the other youths. The SP went outside and told the AV to go inside the facility, but the AV did not, and the SP called the AV a “big dumb bitch.” The AV eventually re-entered the facility and the SP apologized to the AV, saying that s/he “did not mean it.” The next day, the AV was again outside the facility without permission, and the SP placed the AV in a restraint then “threw” him/her in the “snow.” The AV and the SP re-entered the facility and the AV went to his/her bedroom, followed by the SP, who stood in the AV’s bedroom doorway to prevent the AV from exiting the bedroom. The AV was upset and slapped the SP’s face, then the SP slapped the AV’s face. The AV continued to hit/slap the SP until P1 arrived and successfully redirected the AV to talk with him/her. The AV was unsure how long s/he was outside on the aforementioned dates. · The SP did not respond to this investigator’s requests for an interview or attempts to contact him/her via telephone and email. However, in the facility’s Internal Review, the SP stated that on January 29, 2022, s/he called the AV a “big dumb bitch” when redirecting the AV, then apologized to the AV later when s/he “felt bad about it.” In addition, on January 30, 2022, the SP was very frustrated with the AV because the AV was frequently running around outside the facility attempting to speak with other children through their bedroom windows. The SP redirected the AV into the facility (but did not discuss whether s/he used a Handle With Care procedure to bring the AV into the facility) and then stood in the AV’s bedroom doorway, blocking him/her from exiting the bedroom. The AV slapped the SP on the face several times and the SP slapped the AV’s face once, then immediately realized that s/he should not have slapped the AV. The SP continued to stand in the AV’s doorway while the AV hit/slapped him/her until P1 came to assist the SP and then walked away from AV, keeping his/her distance from the AV for the rest of his/her shift. A Restrictive Procedure Report completed by the SP stated that at 8:33 p.m., on the evening of January 30, 2022, s/he placed the AV in a restraint and transported him/her from outside the facility to his/her bedroom, and then released the AV. The SP documented that the restraint lasted three minutes. A Hold Debriefing Form, completed by an unspecified staff person, stated that the AV did not have injuries. · P1 said that on January 30, 2022, the AV was “running around” outside the facility when P1 checked on children who were in their bedrooms inside the facility. The SP went outside to redirect the AV inside, because it was cold and dark. The AV declined to enter the facility and the SP then placed the AV in a “primary restraint technique” and they walked back into the facility together. P1 said that the restraint looked consistent with the Handle With Care techniques s/he had learned. P1 went to assist the SP with the AV in his/her bedroom, and as s/he approached, s/he heard the AV throwing/breaking things in the bedroom. P1 “switched out” with the SP, who had been standing in the AV’s bedroom doorway, and talked with the AV to help him/her calm. The AV did not tell P1 that the SP had hit him/her, but initially stated that s/he fell into the snow, then said that the SP pushed him/her into the snow. There was snow on the AV’s clothing, but it was “snowy” outside. P1 did not witness the AV in contact with the snow, see the SP hit/him her, or hear the SP call the AV a “big dumb bitch” the day before. · P2 said that on February 1, 2022, s/he talked with the AV regarding the incident on January 30, 2022. The AV told P2 that the SP called him/her a “big dumb bitch” on January 29, 2022, and pushed the AV into the snow, and also said that the SP slapped him/her on January 30, 2022. P2 did not observe any injuries to the AV, but immediately requested a facility health care professional (HCP) to evaluate the AV. According to P2, staff persons were permitted to use Handle With Care procedures to restrain/transport children when necessary, following the facility’s Behavior Management Policy. · An Injury Report Form, completed by the HCP on February 1, 2022, showed that s/he evaluated the AV for injuries that s/he might have sustained during his/her interactions with the SP. The HCP documented that the AV did not have observable injuries at the time s/he was evaluated. However, the AV told the HCP that s/he had pain in his/her right side lower jaw that improved upon taking an over the counter pain reliever after the incident occurred. According to https://weather.com which was accessed on March 28, 2022, the high temperature and low temperature on January 29, 2022, was -5 degrees Fahrenheit (F). On January 30, 2022, the high temperature was -3 degrees F and the low was -6. Snow was forecasted for January 30, 2022. The facility’s Handle With Care Participant Manual defined the Primary Restraint Technique as a restraint in which staff persons stood behind the individual they intended to restrain, placed a hand under each of the individuals upper arms, placed his/her hands together between the individual’s shoulder blades, and then took a long step back with the right leg, which drew the individual off balance. From this position, a staff person might lower his/her right knee to the floor to slowly lower the individual to a seated position. The Handle With Care Participant Manual provided to this investigator did not show how a single staff person might use the Primary Restraint Technique to escort or move an individual. The facility’s Behavior Management Policy stated that physical restraint using the techniques described in the Handle With Care Participant Manual was an approved restrictive procedure that could be used to guide an individual to a place where s/he would be safe and could be used in emergency situations in response to imminent danger to the resident or others and when less restrictive interventions are determined to be ineffective. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Maltreatment of Minors Act prior to the incident. The SP was trained on Conflict Resolution and De-escalation Techniques on March 16, 2021, and on the Residential Programs Policy and Procedure Manual on October 7, 2021. Conclusion: A. Maltreatment: The AV said that on January 29, 2022, s/he had an interaction with the SP during which the SP called him/her a “big dumb bitch.” The SP apologized, but the next day, the SP placed the AV in a restraint and threw him/her into the snow outside. The SP and AV re-entered the facility, and the SP followed the AV into his/her bedroom, then stood in the bedroom doorway. The AV slapped the SP, the SP then slapped the AV, and the AV continued slapping the SP until P1 redirected the AV. No known witnesses heard the SP call the AV a big dumb bitch or saw the SP slap the AV, and it was unknown how long the AV was outside on January 29 or 30, 2022. The SP did not respond to this investigator’s requests for an interview. However, information was consistent that the SP told P2 that s/he called the AV a “big dumb bitch” and slapped the AV. P1 saw the SP restrain the AV and said that the restraint looked consistent with the training P1 was given. When the AV told P2 that the SP slapped him/her, an HCP immediately evaluated the AV, who told the HCP that s/he had jaw pain, but there were no visible injuries to the AV. Facility policies and procedures showed that children could be restrained using approved restrictive procedures in response to imminent danger to themselves or others when less restrictive interventions were ineffective. Although there was no information that the AV sustained an injury, the SP’s action of slapping the AV in the face was not accidental and therefore, there was a preponderance of the evidence that the actions seriously endangered the AV's physical or mental health, and represented a substantial risk of physical or mental injury. It was determined that physical abuse occurred ("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). 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 responsible for the care of the AV at the time of the incident. The SP received training on the facility’s policies and procedures in October of 2021, and was specifically trained on Conflict Resolution and De-escalation Techniques on March 16, 2021. 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 did not meet statutory criteria to be determined as recurring or serious. The SP was responsible for a single incident and there was no information that the AV sustained an injury which met the definition of “serious.” Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. At the time this report was written, the SP was no longer employed at the facility. 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. 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: Ivy House

report_date: September 17, 2025

raw_content:
September 17, 2025

Amber Collins, Authorized Agent

Southern Minnesota Crisis Nursery

15890 Oakwood Heights Road

New Ulm, MN 56073

License Number: 1085292

CORRECTION ORDER

Dear Amber Collins:

A Department of Human Services (DHS) licensor conducted a licensing review of your facility, Ivy House located at 717 5th Street North, New Ulm, MN 56073. 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, and shelter program 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 follow licensing rules and statutes, as described below.

Practice

1. Violation: The license holder’s administration of medications review practice did not meet requirements. A medically licensed person did not review the license holder’s administration of medications in calendar months December 2024 and April 2025.

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

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

Personnel Files

2. Violation: One of five personnel files reviewed for requirements governing orientation training (personnel file numbered 3) did not meet requirements. The file did not contain the following documentation:

a. Training on the following according to the license holder’s policy:

1. Emergency procedures;

2. Maltreatment of minors;

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

4. Operational policies and procedures of the license holder; and

5. Data practices.

b. Training on the license holder’s drug and alcohol policy.

Statute/Rule Violated: Minnesota Statutes, section 245A.04, subdivision 1, paragraph (c); and Minnesota Rules, part 2960.0100, subpart 3, item A.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation for training for staff numbered 3 that demonstrates compliance.

3. Violation: One of five personnel files reviewed for requirements governing ongoing training (personnel filed number 3) did not meet requirements. The file did not contain documentation the staff had ongoing training that must help staff meet the needs of the residents and include skills development in calendar years 2023 and 2024.

Rule Violated: Minnesota Rules, part 2960.0100, subpart 3, item B

Corrective Action Order: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation of ongoing training for staff numbered 3 that demonstrates compliance.

4. Violation: One of five personnel files reviewed for requirements governing emergency procedures (personnel file numbered 3) did not meet requirements. The file did not contain documentation the staff was trained on emergency procedures every six months in calendar year 2024.

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

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

Resident Files

5. Violation: Three of three resident files reviewed for requirements governing resident admission documentation (resident files numbered 1 through 3) did not meet requirements. The file did not include a description of presenting problems, including circumstances leading to admission.

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

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

6. Violation: Three of three resident files reviewed for requirements governing shelter programs (resident files numbered 1 through 3) did not meet requirements. The file did not contain the following documentation that the license holder assessed the resident’s:

a. Vulnerability to maltreatment and developed a plan to reduce the resident’s risk of maltreatment while in shelter; and

b. Situation, condition, and immediate needs as a basis for developing a plan to meet the resident’s needs for basic services.

Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item A

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

7. Violation: Three of three resident files reviewed for requirements governing plan for immediate needs (resident files numbered 1 through 3) did not meet requirements. The file did not contain a plan for immediate needs.

Rule Violated: Minnesota Rules, part 2960.0520, subpart 3

Corrective Action Ordered: Immediate and on an ongoing basis, the license holder must ensure plan for immediate needs meets all applicable requirements. Within 30 days of receipt of this order, submit a plan for immediate needs for two residents that demonstrates compliance.

8. Violation: One of three resident files reviewed for requirements governing return of resident’s property (resident file numbered 1) did not meet requirements. The file did not contain documentation of the resident’s medication returned upon discharge.

Rule Violated: Minnesota Rule, part 2960.0090, subpart 3

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure return of resident’s property meets all applicable requirements.

Written Response Required

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

If submissions are required as part of the corrective action ordered, they must be sent to your licensor by email at laura.huff@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Laura Huff

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited 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 651-431-6957 or 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/

doc_type: Correction Order


facility_name: Jelani House

raw_content:
April 28, 2023

Carmeann Foster, Authorized Agent

Rebound Inc.

710 W Broadway Ave N

Minneapolis, MN 55411

License Number: 1100893

CORRECTION ORDER

Dear Carmeann Foster:

On January 23 through 26, 2023 a licensing review and licensing investigation of Jelani House located at 221 Belvidere St. E., St. Paul, MN 55107, 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, group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and residential shelter services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). As a result of this licensing review and 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 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.

Postings

1. Citation: Minnesota Statutes, section 245A.65, subdivisions 1, paragraphs (a) and 2, (d); and Minnesota Rules, part 2960.0050, subpart 3, item D.

Violation: The license holder failed to ensure postings met requirements in the following ways:

a. A copy of the internal and external reporting policies and procedures for maltreatment were not posted in a prominent location in the facility;

b. The license holder maintained a posting of an outdated program abuse prevention plan (PAPP); and

c. A copy of the resident’s rights was not posted in the staff work station.

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

Policies and Practices

2. Citation: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (4) and Minnesota Rules, part 2960.0020, subpart 44; 2960.0030, subpart 2, item B; 2960.0010, subparts 1 and 2; 2960.0040, item D.

Violation: The license holder did not notify the Commissioner or obtain approval prior to changing the location of the services provided by Jelani House. The license holder moved residents from the location identified for license number 1100893, Jelani House, to the location of a different licensed facility of the license holder, license number 1076796, Jordan House. Residents slept overnight at Jordan House and attended group services and activities.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure to meet all applicable requirements. During the licensing review, the license holder was ordered to immediately cease the combining of residential programs for overnight sleeping.

3. Citation: Minnesota Statues, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, part 2960.0050, subpart 1, item B

Violation: The license holder failed to monitor the implementation of their Cell Phone Protocol policy and to ensure the residents right to privacy was protected. As a result, a critical incident occurred on August 6, 2022 (resident file numbered 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their policies meets all applicable requirements.

4. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: The license holder failed to monitor the implementation of their plan for the safe storage and delivery of medicine in the following ways:

a. Documentation did not demonstrate that a medically licensed person provided consultation and review of the administration of medications at least monthly for the months of October, November, and December 2022;

b. Staff persons responsible for the administration of medications to residents were not provided program specific medication assistance training by the program’s registered nurse;

c. Documentation to demonstrate whether medications were packed for home visits or when the resident was away from the facility was inconsistent with the plan;

d. Resident documentation indicated that a staff person responsible for administering medications did not have access to the medication locker to administer prescribed medications when the plan indicated they should, resulting in medications not being administered as directed by the prescriber; and

e. The process for obtaining and documenting the need for medication refills was not followed as described in the plan. As a result, resident medication was not administered as directed by the prescriber.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their health services policies and procedures meets all applicable requirements. Within 60 days receipt of this order, submit documentation demonstrating the plan for the safe storage and delivery of medicine was reviewed and approved by the program’s current medically licensed professional to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021

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

Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not include the following required performance indicators:

a. Accidents;

b. The use of restrictive procedures;

c. Grievances;

d. Results from resident and family satisfaction surveys; and

e. Critical incidents

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021

6. Citation: Minnesota Statues, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subparts 6 and 17, item A.

Violation: The license holder failed to meet requirements governing critical incidents in the following ways:

a. Critical incident reports were not submitted to DHS for six incidents in which a resident absconded and did not return within 24 hours (July 25 and 26, 2022, August 10, 2022(x2), and September 13 and 26, 2022);

b. The license holder’s Critical Incident Reporting and Review policy did not define critical incidents according to DHS’s definitions and criteria; and

c. The license holder failed to monitor the implementation of their Critical Incident Reporting and Review and Abscond policies in the following ways:

1. Incidents were not documented on the forms or maintained in the resident’s record as described in the Critical Incident Reporting and Review policy; and

2. The notifications to a resident’s referring agent for when a resident ran from the program were not documented in case notes as indicated in the Abscond policy.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their incident reporting policies and procedures meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021

7. Citation: Minnesota Rules, part 2960.0080, 18, item A.

Violation: The license holder did not meet requirements governing grievances. The license holder did not demonstrate that a grievance was responded to according to requirements. A DHS Licensor observed through documentation that a grievance, dated August 6, 2022, was filed and the license holder was unable to provide documentation that it was responded to.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

Personnel Files

8. Citation: Minnesota Statutes, section 245A.041, subdivision 5.

Violation: Two of two personnel files reviewed for requirements governing documentation requirements (personnel files numbered 1 and 3) did not meet requirements. The license holder failed to document the first date the staff person began working in a facility or setting.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements.

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

Violation: Two of two personnel files reviewed for requirements governing orientation training (personnel files numbered 1 and 3) did not meet requirements in the following ways:

a. The staff person was not oriented to general and special needs, including disability needs of families served; and

b. The staff person was not oriented within 72 hours of first providing direct contact services to the program abuse prevention plan (PAPP).

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

Resident Files

Resident files reviewed are identified in the following manner:

· Shelter: Resident file numbered 2

· Group Residential Setting: Resident file numbered 1

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

Violation: Two of two resident files reviewed for requirements governing resident information did not meet requirements. The resident file did not include the following required information:

a. Time of admission (resident files numbered 1 and 2);

b. Resident’s written language and tribal affiliation (resident file numbered 2);

c. Circumstances leading to admission (resident files numbered 2);

d. Description of assets and strengths of the resident (resident file numbered 2);

e. Spiritual or religious affiliation of the resident the resident’s family (resident file numbered 2); and

f. Attempts to obtain the placing agency’s case plan goals (resident file numbered 1).

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

11. Citation: Minnesota Rules, parts 2960.0160, subparts 2, item C.

Violation: One of two resident files reviewed for requirements governing admission criteria (resident file numbered 1) did not meet requirements. The file did not contain documentation to demonstrate that the license holder determined they were able to meet the resident’s cultural, emotional, educational, mental health and physical health needs.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

12. Citation: Minnesota Rules, parts 2960.0070, subpart 4 and 2960.0090, subpart 3.

Violation: Two of two resident files reviewed for requirements governing the inventory and handling of resident property did not meet requirements in the following ways:

a. The resident’s property was not inventoried upon admission (resident files numbered 1); and

b. The files did not include a signed receipt demonstrating the license holder returned all of the residents’ personal property (resident files numbered 1 and 2).

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

13. Citation: Minnesota Rules, parts 2960.0520, subparts 2, items A and B, and 3.

Violation: One resident file reviewed for requirements governing shelter admissions (resident file numbered 2) did not meet requirements in the following ways:

a. A health screening was not arranged for within 24 hours of admission;

b. The license holder did not assess the resident’s vulnerability to maltreatment and develop a plan to reduce their risk of maltreatment while in the shelter; and

c. An immediate needs plan was not developed.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

14. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0530, subpart 1.

Violation: One resident file reviewed for requirements governing limitations on length of stay in shelter (resident file numbered 3) did not meet requirements. The file did not contain documentation to demonstrate that the license holder applied for a variance to retain a resident in shelter beyond 90 days or followed their policy to transfer an individual from shelter to group residential services.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

15. Citation: Minnesota Rules, part 2960.0070, subpart 5, item A.

Violation: One resident file reviewed for requirements governing resident screenings (resident file numbered 1) did not meet requirements. The file did not contain documentation to demonstrate that the license holder completed a mental health and substance use disorder screen.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

16. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D.

Violation: One of two resident files reviewed for requirements governing program services (resident files numbered 1) did not meet requirements. The license holder did not demonstrate that education about chemical health was provided to a resident who has had a problem with inappropriate chemical use, but who does not have sufficient history to refer to treatment.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

17. Citation: Minnesota Rules, part 2960.0180, subpart 2, item B.

Violation: One resident file reviewed for requirements governing treatment plans (resident file numbered 1) did not meet requirements. There was no date on the treatment plan to determine that its development began within 10 days of admission.

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

18. Citation: Minnesota Rules, part 2960.0080, subpart 11, items D and E.

Violation: One of two resident files reviewed for requirements governing health care (resident file numbered 1) did not meet requirements in the following ways:

a. The medication administration record for the months of November and December 2022, did not identify whether the resident received the medication on the following dates:

1. November 3,4, 8, 12, 19, 24 and 25, 2022; and

2. December 13, 5, 8-12, 15, 17, 21-25, and 27-31, 2022;

b. There was no documentation to demonstrate the license holder contacted the resident’s prescribing medically licensed person to verify information regarding their prescription medication;

c. There was no documentation to demonstrate the license holder followed the prescribing physician’s directions for monitoring medications used by the resident; and

d. There was no documentation to demonstrate the license holder recorded the initial quantity of medication received by the pharmacy.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

19. Citation: Minnesota Rules, part 2960.0090, subpart 2.

Violation: One resident file reviewed for requirements governing a no-eject discharge (resident file numbered 2) did not meet requirements. The file did not contain documentation to demonstrate the following:

a. The license holder conferred with other interested persons to review the issues involved in the decision to discharge a resident prior to reaching their case plan goals;

b. If any additional strategies to resolve the issues leading to discharge could have been developed to allow the resident opportunity to continue receiving services; and

c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

20. Citation: Minnesota Rules, parts 2960.0190, subparts 1, items A and C, and 2, items A and B; and 2960.0520, subpart 2, item C.

Violation: One resident file reviewed for requirements governing discharge procedures, documentation, and the transition services plan (resident file numbered 1) did not meet requirements in the following ways:

a. There was no documentation to demonstrate the resident’s projected discharge date was provided to all applicable parties;

b. The transition services plan did not include the following:

1.  The date it was completed;

2.  Resources available in the community to address the resident’s continued needs after discharge from the program;

3.  Consideration of the environment the resident will return to and recommendations of how they might deal with potential issues and challenges within that environment;

4.  Documentation to demonstrate the plan was developed with input from the resident, the resident’s family, and if appropriate, the providing school district, and anyone who will provide support services upon discharge from the program; and

5.  Documentation to demonstrate that a copy of the plan was given to the resident, the school, or if applicable, to the residential treatment facility the resident was placed in upon/after discharge; and

c.   The discharge documentation did not identify the extent to which the resident’s stay in the program met the goals and objectives of their treatment plan and who provided those services.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

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: tina.christensen@state.mn.us; or

2. By mail to:

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 Senior 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/