facility_name: Aspen House

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: 202511721

Date Issued: April 14, 2026

Name and Address of Facility Investigated:

Aspen House
2031 Victoria Road South
Mendota Heights, MN 55118

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

License Number and Program Type:

1114282-CRF (Children’s Residential Facility)

Investigator(s):

Samantha Wueste

Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-2278

Samantha.wueste@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) and an alleged victim (AV) had a verbal “altercation” where the SP used derogatory language towards the AV causing the AV and other facility residents (R1-R5) to become “dysregulated” and/or “agitated,” leading to a physical interaction between the AV and the SP which later resulted in legal implications for the AV. It was further reported that during the incident, the AV hit the SP in his/her face and that the SP responded by “swinging back” at the AV with a closed fist and “hitting” the AV’s face “at least” two times. Additionally, during this incident, R4 and R5 each responded with physical aggression towards the AV which then led to multiple physical interactions between the AV and R4 shortly thereafter. At some point during this situation, the AV sustained “a black eye.”

Date of Incident(s): December 15, 2025

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a):

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.

"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 visit conducted on January 29, 2026; from documentation at the facility, law enforcement records, and medical records; and through eight interviews conducted with the AV, the SP, the AV’s Guardian ad Litem (GAL), the AV’s case manager (CM) who was also the AV’s guardian at the time of the incident and during the AV’s placement at the facility, the AV’s family member (FM) who was later established as the AV’s guardian upon his/her discharge from the facility, two supervisory staff persons (P2 and P3), and an administrative staff person (P4). Multiple attempts were made via phone to contact and interview an additional staff person (P1), but the attempts were not successful. This investigator met P5 during the site visit but P5 declined to provide information for this investigation at that time.

At the time of this investigation, R1, R3, and R4 no longer resided at the facility.

The facility was a short-term shelter for youth ages 11-18 who needed a temporary, safe place to live. In addition to temporary housing, youth who lived at the facility were also provided with supports and services that included medication management, gaining/continuing education, building social support and independent life skills, individual/group therapy, recreational activities, transportation, supervision, and accessing mental health services and community resources. The facility operated/staffed three shifts from 7 a.m. to 3:30 p.m. (first shift), 3 to 11:30 p.m. (second shift), and 11 p.m. to 7:30 a.m. (overnight shift) and provided a minimum of three to four staff persons each shift including a supervisory staff person who was scheduled on-site and/or remotely.

The main level of the facility towards the front of the building contained a secured entry way, two staff offices, a bathroom used by facility staff and/or visitors, a laundry room, and access to a multi-purpose room (the “Treehouse”), a kitchen, and a third staff office (“staff room”) that each connected to a large common area (the “milieu”) which used furniture placement to divide the space into three distinct areas for schooling (the “classroom area”), eating (the “Café”), and lounging (“Unplugged”). The milieu also connected to multiple hallways that led to three pods, with each pod containing four youth bedrooms and a shared bathroom located on each side of the milieu to the left, directly ahead/towards the rear of the building, and to the right which included the AV’s bedroom. Youth medications were kept in the staff room that was to be locked when not in use and only accessed by staff persons.

The facility had cameras mounted in the common areas, which recorded video but not audio.

The AV was 15 years old at the time of the incident and his/her diagnoses included post-traumatic stress disorder, schizoaffective disorder, and major depressive disorder. The AV enjoyed listening to music, playing video games, and spending time with his/her family members and friends. On December 2, 2025, the AV moved into the facility seeking temporary shelter and care while waiting for alternative placement that was being decided by the Minnesota courts at that time. On January 9, 2026, the AV was discharged from the facility. The AV was 15 years old at the time of the incident.

The facility’s daily activity and staffing schedules showed that on December 15, 2025, the SP and P1-P3 worked the second shift at the facility with the AV and five additional residents (R1-R5). After dinnertime and until bedtime from approximately 6:45 to 10 p.m., the staff and residents followed a “typical” evening routine within the milieu and/or the Treehouse that consisted of “chill time,” nightly medication administration, and a “healthy” snack.

The AV stated that on December 15, 2025, the AV and the SP “got in a fight” after the SP “made fun” of the AV and called him/her names including “stupid” and a derogatory racial slur “[N-word].” [Note: The names that the VA said the SP called him/her should not be used as an indication as to the race of the AV.]

During this verbal interaction, the SP was “smiling” and “pointing” at the AV which caused the AV to “feel” “angry,” “defensive,” and “verbally attacked” by the SP. Shortly after this, P1 and P3 were able to separate the AV and the SP but the AV was “still just mad at everything” that the SP said to him/her. The AV said that s/he then walked up to the SP and hit the SP in his/her face which the SP responded to by “throwing a few punches back” at the AV and “hitting” the AV in his/her face “a few times.” After this, R4 and R5 each “jumped in,” “grabbed “the AV from behind, and started “fighting” the AV. The AV did not know how long this incident lasted but remembered staff separating him/her from R4 and the “cops” arriving to the facility shortly thereafter. The AV was the “only one” who “got in trouble” for the incident and was being criminally charged with assault against the SP which the AV “felt” was “unfair.”

P3 and P4; the AV’s daily Shift Notes and health/safety checks completed by P3 during the facility’s second shift on December 15, 2025; the facility’s incident reports completed by P2, P3, and P4 dated December 16, 2025; and the facility’s Critical Incident Report and Internal Review completed by P4 dated December 22, 2025, provided the following information:

· On December 15, 2025, at approximately 9:30 p.m., P2 told the AV and R1 that each would be receiving a “program pause” (a behavioral intervention limiting a youth’s ability to participate in extracurricular activities/outings that were considered a “privilege”) due to the AV’s and R1’s ongoing behaviors involving inappropriate interactions with one another. The AV then became “irritated but not dysregulated,” took his/her nightly medications from P2, and then went to the Café where the AV had a snack and talked with R1. Shortly thereafter, the AV became “agitated,” walked over to the classroom area, and began “pacing” and “swearing loudly.” R1 also began “swearing loudly” as s/he walked towards P2 who was standing outside of the staff room giving the AV and R1 verbal reminders and redirection to use “appropriate” and “respectful” language. However, R1 ignored P2, received his/her nightly medications, and then continued to talk to P2 using “vulgar” and “offensive” language until R3 told R1 to “act [his/her] age” and to be “respectful” to staff persons.

· At approximately 9:50 p.m., the AV became “agitated” with R3’s comments to R1 and started “swearing loudly” again as s/he made inappropriate hand gestures and walked towards Unplugged where R3 was sitting at that time, along with the SP, P1, R4, and R5. R1 remained outside of the staff room near P2 who administered R2’s nightly medications and provided the AV with verbal redirection. P2 then entered the staff room to record that each youth received his/her medications, respectively, and to store/secure the medications accordingly. P3 was in a staff office near the building’s front entrance.

· At approximately 9:55 p.m., the AV continued to use inappropriate language and hand gestures while showing signs of emotional dysregulation. The SP responded to the AV’s behaviors by engaging in a “back-and-forth” verbal “power struggle” with the AV for “several minutes” while remaining seated in Unplugged near R2, R4, and R5. According to P4, the SP said things the AV to “intentionally upset” him/her and that were not therapeutic including telling the AV that s/he was “stupid” and “making fun” of the AV’s hand gestures. During this time, the AV “looked noticeably agitated” by the SP’s words and “paced” towards and away from the SP with visible escalated behaviors.

· At approximately 9:59 p.m., the AV walked over to where the SP was sitting who at that point stood up, faced the AV, and began to engage in a verbal “altercation” with the AV which caused “all” of the facility residents to become “loud and dysregulated” and “crowd around” the AV and the SP. P1 “quickly” responded to the situation by standing in between the AV and the SP while asking the SP to leave the area. The SP refused to “walk away” from the situation and maintained “confrontational posturing” towards the AV while “taunting” the AV with derogatory remarks related to the AV’s diagnoses and associated behaviors. During this time, R1 and R2 stood next to the AV as R4 and R5 each stood behind the SP while becoming visibly “agitated” including R4 “pacing” with “clenched fists.” R3 then tried to “calm” R4 but was not successful so s/he stood next to P1 and tried to help separate the AV from the SP, R4, and R5. P2 also approached the situation at that time and tried to “calmly” redirect the residents away from the AV and the SP but was not successful. The SP then continued to verbally engage and “argue” with the AV as the SP stood behind P1 and R3 with his/her “arms crossed” refusing to walk away from the situation as requested by P1 and P2 each. At that point, the AV was “very noticeably dysregulated” and tried to “push” past P1 to the SP but P1 was able to use his/her body to block the AV from the SP while R2 attempted to physically redirect the AV away from the situation.

· At approximately 10:01 p.m., after hearing the residents “yelling” and “swearing,” P3 entered the milieu and witnessed the AV and the SP “yelling” at each other. P3 told the SP to “leave the floor” and then walked with the SP, R4, and R5 to Unplugged as P1 walked in the opposite direction with the AV towards the classroom area followed by R1-R3. Shortly thereafter, the SP grabbed his/her personal belongings and walked out of Unplugged towards the front of the building. The AV, who was still “upset” by what the SP had said to him/her, began to walk towards the SP while “threatening” to “knock” the SP’s eyeglasses “off” the SP’s face. As the AV approached the SP in the Café, the SP turned towards the AV and tried to use his/her arm to “shield” him/herself from the AV but the AV hit the SP in his/her face. The SP responded by “swinging back” at the AV and “hitting” the left side of the AV’s face with a closed fist and then “swung” again at the AV who tried to “catch” the SP’s hand/arm but missed. The SP then “punched” the AV’s face two times until P3 was able to position him/herself between the AV and the SP while R4 and R5 “aggressively pulled” the AV away from the SP. R5 “briefly” engaged in a physical interaction towards the AV but then “stopped” and “distanced” him/herself as the SP left the area and R4 continued to engage in a physical “altercation” with the AV. At some point during this time, R4 was able to lift the AV and “body slam” the AV to the floor. Shortly after, staff persons were able to successfully intervene and separate the AV and R4. P2 then redirected R2-R5 to the Treehouse while P1 stayed with the AV and R1. P3 called 9-1-1 to report the incidents to law enforcement (LE). After speaking to LE, P3 contacted and notified the AV’s and R4’s care teams of the incidents.

· At approximately 10:10 p.m., three law enforcement officers (LEO1-LEO3) arrived at the facility and talked with the SP, the AV, and R4 about the incidents. However, R4 and the AV attempted to engage in another physical interaction and so the law enforcement officers separated the AV and R4 and placed each in

handcuffs while trying to talk with each about what happened. Shortly thereafter, the AV and R4 were each transported via ambulance to a local hospital for observation and assessment.

· On December 16, 2025, from approximately 1 to 2 p.m., the AV and R4 returned to the facility after being discharged from the hospital’s care. Staff persons (including P2 and P3) talked with the AV and R4 about the incidents the evening prior. The AV and R4 each apologized to the other and did not have any additional incidents or concerns with their interactions.

· Consistent information was provided that the AV sustained a “black eye” from the incident. However, P2-P4 each stated that s/he was not aware if the AV received the injury as a result of the SP’s actions or from the AV’s interactions with R4.

· P3 and P4 each stated that there were prior concerns with the SP’s interactions that involved times when the SP engaged in “power struggles” with the youth and the SP was then provided additional training. P3 and P4 were not aware of any prior incidents when the SP used derogatory language towards residents and/or had physical interactions with a resident.

P2 provided information that was consistent with the information provided by P3, P4, and facility documentation. P2 also provided the following additional information:

· During the evening on December 15, 2025, “right before room time” at 10 p.m., P2 was in the staff room when s/he overheard the AV and the SP “yelling” and “going back and forth” with each other in a manner that “sounded” like it was “escalating” so P2 left the office to assist with the situation. P2 then saw that the AV and the SP were having a verbal “argument” near Unplugged with P1 standing in between and trying to separate them. P2 approached the situation and P1 told P2 that s/he tried to “tap out” the SP but the SP did not listen. P2 requested that the SP “leave the floor” but the SP ignored P2’s request and continued “taunting, insulting,” and calling the AV names which included racial slurs, “stupid” and “retarded,” which will be referred to as the R-word throughout the remainder of the report. Additionally, the SP was “smirking” at the AV during this time and “appeared very smug” that “seemed very intentional and instigative.”

· Staff persons were trained to help support one another when responding to “challenging” behaviors and/or incidents and to “tap out” another staff person which required the staff person to “immediately leave the floor” if s/he became “frustrated” or was escalating a resident’s behaviors. However, the SP ignored P1’s and P2’s attempts to “tap [him/her] out” during this incident which was similar to incidents prior to this. The SP had a “tendency” to go from “zero to hundred” when responding to a resident’s behaviors which was something that P2 stated, “Even the youth picked up on and commented about.”

The SP provided information that was consistent to information provided by facility documentation relating to the timeline of events and those involved in the incident. The SP provided the following additional information:

· On December 15, 2026, the AV “argued” with staff persons “that whole [second] shift” which included a time earlier that afternoon (prior to the incident) where the AV became “upset” with the SP’s verbal redirection regarding the AV’s use of hand gestures that related to “gang signs.”

· Later that evening, the AV “got mad” and started “arguing” with R3 who had “called out” R1 for being “rude and mean” to P2. The AV then started walking towards Unplugged where the SP, P1, and R3-R5 were sitting at the time which was when the SP “inserted” him/herself. The SP “basically” told the AV that R1’s and R2’s conversation had “nothing to do with [the AV]” and that s/he “needed to stay out of it, […] turn around, and go back over the [staff room]” with P2 and R1. However, the AV was “already frustrated” with the SP from earlier that day so s/he ignored the SP and continued to walk towards Unplugged while “swearing” at the SP, making “threats,” and calling the SP names. The AV told the SP that s/he was going to “fuck [the SP] up,” “punch [the SP],” and “knock [the SP’s] glasses off [his/her] face.” The SP then told the AV that s/he was not going to “touch” or “hurt” the SP and remained seated until the AV approached him/her. The SP then “jumped up out of [his/her] seat” as P1 stood in front of the SP to “protect” him/her. At some point during this “whole heated argument,” P2 and P3 “finally” entered the milieu but “basically just sat on the sidelines, didn't intervene, didn't say anything, and didn't pull me off the floor or anything” so the SP then decided at that time to “walk” and leave the area.

· After the SP started walking towards the staff area, “all of a sudden” P1 “yelled” the SP’s name but as the SP turned around, the AV “punched” the SP two times in his/her face and “knocked [his/her] glasses off.” After the AV “punched” the SP, R4 and R5 “came running in [the SP’s] defense” as the SP was “pulled out” of the situation and “thrown into” the staff room by a person that the SP “thought” to be P3 or another staff person. R4 and R5 then “got into a physical altercation” with the AV “on [the SP’s] behalf” but the SP did not see this happen because s/he remained in the staff room until LE arrived at the facility shortly thereafter. The SP did not “recall” or “remember” responding to the AV with any aggressive behaviors but “may have had a reflex moment afterwards” or a “reaction” that the SP “honestly” was not aware of and/or could recall.

· The SP denied “yelling,” “taunting,” and/or engaging in any type of verbal “argument” with the AV during this incident and/or “making fun” of the AV and calling him/her names. The SP said s/he “never” used derogatory language when interacting with any facility residents that included the AV.

· The SP was not aware of any known interpersonal conflicts between him/herself and other facility staff persons. The SP built a “positive rapport” with all the facility residents but had yet to do so with the AV because s/he was “new” to the facility.

The facility’s video surveillance footage dated December 15, 2025, from 9:50 to 10:10 p.m. (20 minutes) was reviewed by this investigator and was consistent with the information provided by P2-P4 and facility documentation. Although the video footage did not include audio of the incident, the AA’s behaviors and non-verbal cues including body language, facial expressions, and hand gestures, indicated that the AV was frustrated and/or upset with the verbal interactions between him/herself and the SP. However, the SP’s behaviors and non-verbal cues including body posturing and facial expressions indicated that s/he continued to engage with the AV in a manner that appeared combative and that further provoked and escalated the AV’s behaviors. Additionally, the video footage showed that after the AV hit the SP in his/her face, the SP immediately responded by hitting the AV in the face with a closed fist two times.

LE records provided the following information:

· At 10:03 p.m., the facility called 9-1-1 requesting assistance for “a youth fighting a staff member” and LEO1-LEO3 responded shortly thereafter. Dispatch noted that s/he could hear “a lot of screaming in the background” during the phone call.

· LEO1 and LEO2 arrived at the facility and observed LEO3 near the main entrance talking with the AV who had “fresh blood” and “swelling” on his/her face. LEO1 asked the AV what happened but then was not able to talk with the AV at that time due to a “bunch of screaming and yelling” that was coming from directly behind LEO1. LEO1 then turned around and observed R4 walking out of the Treehouse towards LEO1, LEO3, and the AV. R4’s shirt was ripped and “hanging off” his/her body and R4’s face also had “fresh blood” and “swelling.” Shortly thereafter, R4 and the AV each “got in each other’s faces” and started to engage in physical interactions including “shoving” and attempting “punches.” LEO1 placed R4 in a hold while LEO2 assisted in handcuffing and separating R4 and the AV.

· R4 told LEO1 that there was an “argument” between the SP and the AV that escalated to a physical interaction where the AV “punched” the SP in his/her eye. R4 then “stepped in” to “defend” the SP and began “fighting” the AV. After talking to R4, LEO1 then talked with the SP who had “swelling” of his/her right eye. The SP told LEO1 that the AV “punched” him/her in the face two times with a closed fist which “bent/broke” the frames of his/her eyeglasses that s/he was wearing at that time.

· The LEO arranged for emergency medical service responders to transport the AV and R4 via ambulance to a local hospital for a physical and mental health evaluation. The AV was issued a citation for his/her physical interactions towards the SP and breaking the SP’s glasses, with the charges then sent to the County Attorney for review of possible 5th Degree- Assault and 4th Degree- Damage to Property. [Note: At the time of this report, this was still under review by the county attorney.]

The AV’s hospital records dated December 15 to 16, 2025, provided the following information:

· On December 15, 2025, at approximately 10:45 p.m., the AV was brought in to the emergency department (ED) via ambulance from the facility for a physical and mental health evaluation proceeding an altercation that took place earlier that night.

· The AV told healthcare staff (H) that the SP was verbally aggressive towards him/her which led to the AV physically interacting with the SP who “hit [the AV] back.” After this, R4 and R5 each became involved in this incident and physically aggressed towards the AV punching and scratching the AV’s face. The H observed swelling and bruising around the AV’s left eye and “scattered scratch marks” behind the AV’s ears and on his/her face.

· On December 16, 2025, at approximately 12:30 a.m., a social worker (SW) from the hospital contacted the facility to arrange the AV’s discharge from the and transportation back to the facility. At that time, a facility staff person told the H that the AV was unable to return to the facility until the AV’s care team had discussed the incident. The SW told the staff person that the AV was ready for discharge and could not stay at the ED overnight. Because the facility did not make any further contact with the SW, the AV remained at the ED until another placement was available. Later that morning, the H contacted the AV’s care team including the CM, and at approximately 12 p.m., the AV was discharged and transported back to the facility via ambulance.

The FM was appointed guardianship of the AV on January 9, 2026, and was “only” aware of the incident from information that the AV shared with him/her which was consistent to the information that the AV also provided to this investigator. Additionally, the FM considered the AV to provide accurate information

The CM stated that s/he was aware of the incidents and did not have any additional information to provide regarding the allegation. Additionally, the AV “might” provide accurate information but also “might leave out important details or misinterpret events, especially if [the AV] felt that [s/he] was in trouble” for his/her behaviors.

The GAL was contacted regarding this investigation but did not have additional information specific to the allegations.

Physical and/or electronic copies of the facility’s handbooks were provided to “all” facility staff and residents which contained the facility’s policies and procedures including the following:

· The “principal role” of the facility’s staff was to keep youth emotionally and physically safe.

· Staff were responsible for “always upholding” a youth’s rights which included rights to positive and proactive adult guidance, support, and supervision; to courteous and respectful treatment; and to be free from abuse and harassment.

·  Staff were to encourage youth to follow the facility’s expectations by building positive relationships, role modeling, coaching, teaching, and using collaborative problem solving with youth.

· During times when a youth did not follow expectations and/or had disruptive or unsafe behaviors, staff persons were to respond by further building a relationship with the youth; providing verbal prompts, reminders, choices, and redirection; encouraging the youth to use a healthy coping skill or take a break; providing the youth with space to talk; collaborating with the youth to problem solve and to develop a plan of “getting back on track;” remain with the youth while providing guidance and de-escalation as needed; and/or temporarily “pausing” the youth’s involvement in extracurricular programming. Additionally, staff were to consider how s/he might be helping or harming a situation.

· During times when a youth was “disrespectful,” staff were to respond with “grace and strength” and not escalate the situation. Additionally, staff were to refrain from engaging in “power struggles” with youth.

· “Any staff may execute a tap-out for a colleague at any time … Staff tapping-out must step off the floor for at least 30 minutes.”

· Staff were responsible for their own behavior and choices.

Facility documentation showed that the SP and P1-P4 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act prior to the incident.

Conclusion:

A. Maltreatment:

Consistent information was provided by P2-P4, and facility documentation including video, that on December 15, 2025, the AV and the SP engaged in a verbal and physical altercation where the SP had “confrontational posturing,” used language that was not therapeutic or consistent with facility policies that included calling the AV “stupid,” “intentionally” provoking and escalating the AV’s behaviors, and refusing to disengage from the conversation or “tap out” from the situation as requested by P1 and P2 during the time. P2 also provided information that during the verbal altercation between the AV and the SP, the SP was “smirking,” “taunting, insulting,” and calling the AV names which included racial slurs, “stupid” and “R-word.” The SP’s interactions with the AV caused the AV and R1-R5 to become “agitated” and/or “dysregulated.” At one point, the AV hit the SP in his/her face and the SP responded by hitting the AV in his/her face with a closed fist two times.

The SP denied “yelling,” “taunting,” “making fun of,” and/or calling the AV names. The SP also denied engaging in any type of verbal “argument” with the AV during this incident and/or using derogatory language when interacting with any facility residents that included the AV. The SP did not “recall” or “remember” responding to the AV with any aggressive behaviors but “may have had a reflex moment afterwards” or a “reaction” to when the AV “punched” him/her that the SP “honestly” was not able to recall.

Regarding neglect

Although the SP denied the allegations in this report, given the information above, that the SP had reason to minimize his/her actions, and that P2-P3 each provided information about the incident which corroborated with the information that was shown in the video footage, it was more likely that the SP engaged in the actions as described by the AV and P2-P4. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were a violation of the facility’s policies and procedures, and likely hindered the AV’s ability to have a trusting relationship with the facility’s staff persons which might interfere with other attempts to provide the AV with therapeutic services, both now and in the future.

Given the aforementioned and the egregious nature of the “N-word” and the “R-word,” there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and/or a failure to protect the AV from actions that seriously endangered his/her 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 and/or 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).

Regarding physical abuse

Although the SP did not recall having any physically aggressive behaviors towards the AV, given that the video of the incident showed the SP hit the AV in the face with a closed fist twice which was not accidental, there was a preponderance of the evidence that the SP engaged in conduct that was not accidental causing physical and/or threatened injury to the AV.

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.

Facility documentation showed that the SP received training on the facility’s policies and on the Reporting of Maltreatment of Minors Act prior to the incidents.

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 and physical abuse for which the SP was responsible was not “recurring” maltreatment because it was a single incident that met two definitions of maltreatment; and it did not meet the definition of being “serious” maltreatment because it was unclear whether the AV sustained the injury to his/her eye as a result of the SP’s actions or during proceeding physical interactions with R4.

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 and determined that policies and procedures were adequate but not followed by the SP on December 15, 2025. The facility provided additional training to all staff regarding de-escalation techniques. The SP no longer worked 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/


state: MN

report_date: February 27, 2023

raw_content:
February 27, 2023

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 N., Suite 500

Plymouth, MN 55441

License Number: 1114282

Investigation Report Number: 202210252

CORRECTION ORDER

Dear Michelle Murray:

On December 19 through 21, 2022, a licensing review and licensing investigation of Aspen House, located at 2031 Victoria Rd. S., Mendota Heights, MN 55118, 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 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.

Policies and Practices

1. Citation: Minnesota Statutes, section 245A.65, subdivision 1.

Violation: The license holder failed to develop policies and procedures for vulnerable adult maltreatment reporting requirements.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of training meets all applicable requirements. Within 30 days of receipt of this order, submit policies and procedures for vulnerable adult maltreatment reporting to demonstrate compliance.

Personnel Files

2. Citation: Minnesota Statutes, sections 245A.65, subdivision 3, and Minnesota Rules, part 2960.0100, subpart 3, item A, and 5.

Violation: One personnel file reviewed for requirements governing orientation training (personnel file numbered 1) did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the staff person was oriented to the following before having unsupervised contact with residents:

1. Emergency procedures; and

2. Maltreatment of Minors reporting requirements; and

b. There was no documentation to demonstrate that the staff person was oriented to vulnerable adult maltreatment reporting policies and procedures or the license holder’s program abuse prevention plan, within 72 hours of first providing direct contact services.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation demonstrating all staff have been trained on all vulnerable adult maltreatment reporting policies and procedures, and the program abuse prevention plan.

Resident Files

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

Violation: One resident file was reviewed for requirements governing resident information (resident file numbered 1) and did not meet requirements. The resident’s file did not include the placing agency’s case plan goals nor the documented attempts made by the license holder to obtain the placing agency’s case plan for the resident.

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

4. Citation: Minnesota Rules, part, 2960.0520, subpart 2, item A.

Violation: One resident file was reviewed for requirements governing the assessment of vulnerability (resident file numbered 1) and did not meet requirements in the following ways:

a. The assessment of the resident’s vulnerability to maltreatment was incomplete. The license holder utilized an Individual Abuse Prevention Plan (IAPP) to assess the resident’s vulnerability to maltreatment, but the IAPP template did not include an assessment of all types of maltreatment for minors as defined in Minnesota Statutes, section 260E.03, subdivision 12; and

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

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission screens, assessments, and risk plans for immediate needs meet all applicable requirements. Within 30 days receipt of this order, submit an assessment of maltreatment and a plan to reduce the resident’s risk for maltreatment for one resident to demonstrate compliance.

5. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: One resident file was reviewed for requirements governing the Individual Abuse Prevention Plan (IAPP) (resident file numbered 2) and did not meet requirements. The IAPP did not contain the following:

a. Specific measures to be taken to minimize the risk of abuse to that person when the individual assessment indicates the need for measures;

b. A statement that indicates the vulnerable adult does not need specific risk reduction measures in addition to those identified in the Program Abuse Prevention Plan (PAPP); and

c. Demonstration that the vulnerable adult participated in the development of the IAPP to the full extent of the person’s abilities.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of maltreatment of vulnerable adults meets all applicable requirements. Within 30 days receipt of this order, submit a revised IAPP template that meets all applicable requirements to demonstrate compliance.

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

Violation: One resident file was reviewed for requirements governing health services (resident file numbered 1) and did not meet requirements in the following ways:

a. The immediate needs plan indicated a medical need for a dental and vision appointment and that staff would assist in scheduling the appointments, though there was no documentation to indicate the appointments were scheduled or provided;

b. The medication administration record did not include the time the medication was taken; and

c. The medication administration record was incomplete and did not identify if a medication was taken or refused.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. Within 30 days receipt of this order, submit a medication administration record (MAR) template that meets requirements.

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

Violation: One resident file was reviewed for requirements governing a no-eject discharge (resident file numbered 1) and did not meet requirements. The file did not contain documentation of 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.

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/

doc_type: Correction Order


facility_name: Avanti Center for Girls

report_date: September 12, 2025

raw_content:
September 12, 2025

Katie Perzel, Authorized Agent

Volunteers of America of Minnesota

10300 Flanders Street NE

Blaine, Minnesota 55449

License Number: 1049979

Report Number: 202408434

CORRECTION ORDER

Dear Katie Perzel:

On June 27, 2025, a Department of Human Services (DHS) licensor conducted a licensing investigation at your facility located at 10300 Flanders Street NE, Blaine, Minnesota 55449. As a result of this investigation, DHS determined that you are in violation of one of the Minnesota rules. As a result, DHS is issuing this order which requires you to take the correction action as described below. 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.

Resident File

Violation: One resident file reviewed did not meet no eject requirements (resident file numbered 1). Documentation did not demonstrate that the license holder conferred with other interested persons to review the issues involved in the decision, nor to develop additional strategies to resolve the issue.

Rule Violated: Minnesota Rules, chapter 2960.0090, subpart 2

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

Written Response Required

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

Submissions required as part of the corrective action ordered must be sent to your licensor by email (hannah.horsch@state.mn.us) or 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.

· 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 651-431-5909.

Sincerely,

Michael Cihla, 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/


raw_content:
May 9, 2024                    CERTIFIED MAIL

Su-Fei Wong, Authorized Agent

Avanti Center for Girls

7625 Metro Blvd Ste 200

Minneapolis, MN 55439-3057

License Number: 1049979 (CRF)

Report Number: 202306651

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATION

Dear Su-Fei:

The Department of Human Services (DHS) is ordering you to pay a fine of $200 for a background study violation. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order based on your failure to comply with the following background study requirement:

Background Study Violation Determined on March 5, 2024:

1. As a result of an investigation, a DHS licensor determined that you failed to remove a disqualified individual from direct contact with people served by your program after receiving notice of your obligation to do so from DHS.

On July 13, 2023, DHS instructed the license holder to immediately remove SP1 from any position allowing direct contact with, or access to, persons receiving services. During the licensing review on March 5, 2024, the DHS licensor determined that the license holder allowed SP1 to continue to provide direct contact services on and after notification from DHS to immediately remove SP1.

Statute Violated: Minnesota Statutes, section 245C.18.

Fine: $200 (one violation at $200 per violation)

Corrective Action Required: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C.

Billing and Payment of the Fine

DHS will send you an invoice for the $200 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

Your Right to Appeal

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you receive 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

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal Authority for this Licensing Action

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

· NetStudy 2.0 is defined by Minnesota Statutes, section 245C.02, subdivision 13e.

Questions

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

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

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

doc_type: Notice of Violation


raw_content:
May 6, 2024

Su-Fei Wong, Authorized Agent

Avanti Center for Girls

7625 Metro Blvd Ste 200

Minneapolis, MN 55439-3057

License Number: 1049979 (CRF)

CORRECTION ORDER

Dear Su-Fei:

On March 4 through 7, 2024, Department of Human Services (DHS) conducted a licensing review at your facility located at 10300 Flanders Street NE, Blaine, Minnesota, 55449 to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, restrictive techniques standards under Minnesota Rules, part 2960.0710 and residential program certification for compliance with the Family First Prevention Services Act, Minnesota Statute, section 245A.25. As a result of this licensing review, a Correction Order is being issued.

LICENSING VIOLATIONS

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

PRACTICES

1. Violation: The license holder did not have a copy of the program abuse prevention plan posted on either living unit. The license holder displayed a summary of the program abuse prevention plan but did not post a plan that contained the full policy.

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

Correction Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. This violation was corrected during the licensing review. No further corrective action is required.

2. Violation: A controlling individual of the program did not annually review and the sign the plan for the transfer of clients and records upon closure for calendar year 2022.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a controlling individual annually reviews the plan for transfer of clients and records upon closure.

3. Violation: The license holder did not have documentation to demonstrate that clinical supervision was provided weekly by a licensed mental health professional for three of three weeks sampled:

a. February 5 through February 11, 2023;

b. September 10 through September 16, 2023; and

c. February 11 through February 17, 2024.

Rule Violated: Minnesota Rules, part 2960.0630, subpart 2, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

4. Violation: The license holder did not provide a written response within five days of the resident filing a grievance on the following dates:

a. October 10, 2022;

b. March 14, 2023;

c. March 20, 2023;

d. April 10, 2023;

e. April 16, 2023;

f. July 9, 2023;

g. July 11, 2023; and

h. November 29, 2023.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must provide written responses to grievances within five days and meet all applicable requirements.

5. Violation: The license holder’s satisfaction surveys provided to former residents and their parents did not contain all required elements, including recreation, sleeping accommodations and the accuracy, usefulness, and appropriateness of the screening and assessment of the resident’s physical and emotional well-being and functioning.

Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, item A.

Corrective Action Required: Immediately and an ongoing basis, the license holder must offer satisfaction surveys that meet all applicable requirements. Within 30 days receipt of the order, submit documentation that demonstrates compliance.

6. Violation: The license holder did not have a process to assess and document a determination of any medical or psychological condition that restraints are contraindicated for and the type of restraints that will not be used on the person based on that determination, prior to using a physical restraint.

Statute Violated: Minnesota Statutes, section 245A.211, subdivision 4.

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

7. Violation: The license holder did not provide vocational skills development services to residents.

Rule Violated: Minnesota Rules, part 2960.0590, item G.

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

PERSONNEL FILES

8. Violation: One of four personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 5). There was no documentation to demonstrate that the staff person received orientation training in emergency procedures.

Rule Violated: Minnesota Rules, part 2960.011, subpart 3, item A.

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

9. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: Documentation did not demonstrate the staff person was trained on:

1. Vulnerable adults maltreatment reporting requirements and definitions in calendar year 2023 (personnel file numbered 2);

2. The license holder’s program abuse prevention plan (personnel files numbered 2 and 7);All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2 and 7);

3. The use of physical holding or seclusion at least once every two years (personnel file numbered 2);

a. Documentation did not demonstrate that the license holder reviewed the emergency plan with staff at least every six months (personnel files numbered 2 and 7);

b. Documentation did not include the name of the entity who provided the training (personnel files numbered 2, 4, and 7); and

Rule/Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subpart 14, part 2960.0100, subpart 3, item A and subpart 5 and part 2960.0710, subpart 9.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

RESIDENT FILES

1. Violation: One of three resident files reviewed for requirements governing resident information did not meet requirements (resident file numbered 5). The file did not contain information about the resident’s tribal affiliation.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

2. Violation: Four of four resident files reviewed for requirements governing qualified residential treatment programs certification did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the license holder contacted and facilitated outreach to each youth’s siblings, including the contact method and each family member’s contact information (resident files numbered 2 and 3);

b. There was no documentation of the contact information for all known biological family members and fictive kin of the youth (resident files numbered 2 and 6);

c. The license holder did not document in the youth’s file how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youths’ siblings (resident file numbered 3); and

d. The program did not provide family-based aftercare support to each youth for at least six months after the youth’s discharge from the program (resident file numbered 7).

Statute Violated: Minnesota Statues, section 245A.25, subdivision 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that qualified residential treatment programs certifications meets all applicable requirements. Within 30 days receipt of this order, submit documentation for two resident files that demonstrates compliance.

3. Violation: One of three resident files reviewed for requirements governing admission criteria did not meet requirements (resident file numbered 1). The file did not contain documentation to demonstrate that the program had assessed whether the program is able to meet the resident’s cultural, emotional, educational, mental health and physical needs.

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

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

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

a. The file did not contain documentation that the license holder completed an inventory of the resident’s personal property, including clothing, upon admission (resident files numbered 1 and 2); and;

b. The file did not contain documentation that the license holder communicated facility rules and due process systems to the resident (resident files numbered 1, 2 and 5).

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4 and 2960.0080, subpart 4

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

5. Violation: One resident file reviewed for requirements governing vulnerable adult orientation and the individual abuse prevention plan did not meet requirements in the following ways (resident file numbered 3):

a. There was no documentation to demonstrate that the resident was oriented to the program abuse prevention plan, policies and procedures governing maltreatment of a vulnerable adult and the internal and external reporting policies including the telephone number for MAARC.

b. The license holder did not develop an individual abuse prevention plan as required when the resident turned 18 years old.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, 2, and 14.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

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

a. The health screening was not completed within 24 hours of admission and did not note the resident’s history of abuse, vulnerability to abuse and potential for self injury (resident files numbered 1, 2, and 5);

b. The cultural screening was completed but did not contain all required screening questions (resident files numbered 1, 2, and 5); and

c. There was no documentation to demonstrate that the license holder completed the screening to determine the resident’s gender based needs (resident file numbered 2).

Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items B and C.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

7. Violation: One resident file reviewed for requirements governing program services did not meet requirements (resident file numbered 1). The license holder did not provide education about chemical health to a resident who has had a problem related to inappropriate chemical use, but who does not have a sufficient chemical use history to refer to treatment.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 9, item D.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

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

a. The individual treatment plan was completed by a staff person who was not under the clinical supervision of a mental health professional (resident files numbered 1, 2, and 5);

b. The treatment plan did not identify the treatment strategy (resident files numbered 1 and 2), the individuals responsible for providing treatment (resident files numbered 1, 2, and 5) and a schedule for accomplishing treatment goals and objectives (resident files numbered 1, 2, and 5); and

c. The treatment plan did not permit the use of physical holding and seclusion (resident file numbered 2).

Rule Violated: Minnesota Rules, part 2960.0600, item A, 2960.0630, subpart 3 item B and 2960.0710, subpart 6.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

9. Violation: Two of four resident files reviewed for requirements governing service plan reviews did not meet requirements (resident files numbered 1 and 4). The treatment team did not include and document the use of time-out for each resident during the review of the resident’s treatment plan.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D and Minnesota Rules, part 2960.0600, item A, 2960.0630, subpart 3 item C.

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

10. Violation: One of four resident files reviewed for requirements governing restrictive procedures did not meet requirements in the following ways (resident file numbered 1):

a. On September 3, 2023, the emergency use of physical holding or seclusion did not meet the following conditions: an immediate intervention is necessary to protect the resident or others from physical harm and the physical holding or seclusion used is the least intrusive intervention that will effectively react to the emergency; and

b. On September 3, 2023, documentation of the restrictive procedure did not include an explanation of why less restrictive measures failed or were found to be inappropriate.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items A, B, and K.

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

11. Violation: Three of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident files numbered 1 through 3). The file did not contain documentation to demonstrate the license holder returned the residents property to the resident upon discharge.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3 and 2960.0190, subpart 1, item C.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

12. Violation: Two of three resident files reviewed for requirements governing transition services plans did not meet requirements. There was no documentation that a copy of the transition services plan was provided to the resident’s school (resident files numbered 1 and 2).

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021.

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

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

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

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

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

ATTN: Maddy Gilbertson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Questions

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

Sincerely,

Maddy Gilbertson, Senior Licensor
Licensing Division
Office of Inspector General

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