raw_content:
January 24, 2025

Tony Sanders, Authorized Agent

Grafton Integrated Health Network Minnesota

3150 Shawnee Dr.

Winchester, VA 22601

License Number: 1109203 (PRTF)

Report Number: 202500013

CORRECTION ORDER

Dear Tony Sanders:

On November 18 and 19, 2024, and December 2 through 4, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Grafton Integrated Health Network Minnesota, located at 224 Kray Mill Rd., Cold Spring, MN 56320. This review was conducted to determine compliance with state and federal laws and rules governing the provision of psychiatric residential treatment facilities under the variance to Minnesota Rules, Chapter 2960; R2960V. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Postings, Policies, and Practices

1. Violation: The license holder’s internal review of a report of alleged or suspected maltreatment of a minor did not meet requirements. Internal reviews for reports dated May 20, 2024, and October 23, 2024, did not include the following required components:

a. An evaluation of whether:

i. The policies and procedures were adequate;

ii. There was a need for additional staff training; and

iii. The reported event was similar to past events with the children or the services involved;

b. Based on the results of the internal review, documentation of whether the license holder developed, documented, and implemented a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or the license holder; and

c. The date the internal review was completed.

Statute Violated: Minnesota Statues, 245A.66, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the completion of internal reviews meets all applicable requirements. Within 45 days receipt of this order, submit an internal review for each instance of alleged maltreatment identified above, that includes all required components to demonstrate compliance.

2. Violation: The license holder did not monitor the implementation of a corrective action plan following an incident on March 31, 2024. Documentation demonstrated that the additional training and weekly supervision that was required by the plan was not provided.

Statute Violated: Minnesota Statues, section 245A.04, subdivision 14, paragraph (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure resident’s rights are protected. See the corrective action ordered in violation number 1 to demonstrate compliance.

3. Violation: During the onsite licensing review and investigation, the license holder did not provide the commissioner with timely and complete access to personnel files to demonstrate compliance with applicable statutes and rules. The commissioner must be given access without prior notice and as often as the commissioner considers necessary if the commissioner is conducting a licensing inspection.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 5, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the commissioner’s right of access meet all applicable requirements.

4. Violation: The license holder did not meet requirements governing staff ratios. For the three weeks reviewed (October 27 through November 16, 2024), documentation did not demonstrate the following:

a. That at least one staff person to every three residents present within the living unit was present during awake hours for the following dates:

i. October 27, 28, and 31, 2024, and November 1, 4, 5, 8, 12, and 13, 2024; and

b. That at least one staff person to every six residents present within the living unit was present during sleeping hours for the following dates:

i. October 28 and 29, 2024, and November 3 through 6, 10 through 12, 15, and 16, 2024.

Rule Violated: Minnesota Variance, section R2960V.14, subparts 2 and 3.

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, 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 of staff ratios meet all applicable requirements. Within 45 days receipt of this order, submit two consecutive weeks of unit staff schedules and the corresponding daily resident census per each living unit that demonstrates compliance.

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

a. September 9, 2024, when seven staff persons did not attend; and

b. October 14, 2024, when six staff persons did not attend.

Rule Violated: Minnesota Variance, section R2960V.13.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

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

6. Violation: The license holder did not meet requirements governing quality assurance and improvement. The license holder did not complete a quarterly review that considered the following required components (Quarters 2 and 3 of 2024):

a. Resident outcomes, including identifying ways to improve effectiveness of the services provided to residents and to improve resident outcomes;

b. Restraint data, according to part R2960V.11, subpart 5;

c. Serious occurrences and other significant incidents, including:

i. Determining whether policies and procedures were followed;

ii. Evaluating the staff’s response to the serious occurrence and other significant incidents;

iii. Assessing what could have prevented the serious occurrence and other significant incidents from occurring; and

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

d. Self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF Variance, R2960V, and demonstrating action to improve the program’s compliance with the requirements.

Rule Violated: Minnesota Variance, section R2960V.17, subpart 1.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quality assurance and improvement plan meets all applicable requirements. Within 45 days receipt of this order, submit the 2024 Quarter 4 review that demonstrates compliance.

Personnel Files

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

a. For staff persons responsible for developing, implementing, monitoring, supervising, and/or evaluating positive support strategies, a positive support transition plan, and/or the emergency use of manual restraint, training documentation demonstrated the following:

i. There was no training completed (personnel file numbered 8); and

ii. At least eight hours of core training was not completed (personnel files numbered 1 through 7, and 9 through 10);

iii. The following required Core Training topics were not completed:

1. Staff responsibilities related to restricted and permitted actions (personnel files numbered 1 and 9);

2. The situations in which staff must contact 911 services in response to an imminent risk of harm to the persons or others (personnel files numbered 1 through 7, and 9 through 10); and

3. Personal staff accountability and staff self-care after emergencies (personnel files numbered 1 through 7, and 9 through 10);

b. For staff persons who develop positive support strategies and program managers, an additional four hours of function-specific training based upon the level of responsibility and qualifications, was not completed prior to assuming responsibilities, to the following required topics:

i. Functional behavior assessments (personnel files numbered 2 and 8 through 10);

ii. How to apply person-centered planning (personnel files numbered 1, 2, and 8);

iii. How to design and use data systems to measure effectiveness of care (personnel files numbered 1, 2, and 8 through 10); and

iv. Supervision, including how to train, coach, and evaluate staff and encourage effective communication with the resident and the resident’s support team (personnel files numbered 1, 2, and 8 through 10); and

c. For staff persons in manager positions, a minimum of an additional two hours of function-specific training to the following required topics was not completed (personnel files numbered 1, 2, and 8 through 10):

i. How to include staff in organizational decisions;

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

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

Rule Violated: Minnesota Rules, part 9544.0090, subparts 1 and 2.

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, 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 of staff training for PSR meets all applicable requirements. Within 45 days receipt of this order, submit training rosters demonstrating the staff persons identified above have completed the required training.

8. Violation: One of ten personnel files reviewed for requirements governing the provision of background studies (personnel file numbered 5) did not meet requirements. The license holder failed to either initiate a new background study for an individual following a legal name change or did not notify the background studies division of the legal name change.

Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 7.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure background studies meet all applicable requirements. Within 45 days receipt of this order, submit documentation demonstrating the updated background study has been completed for the staff person identified above.

9. Violation: Seven of ten personnel files reviewed for requirements governing staff files and background study subjects did not meet requirements. The files did not include:

a. The date the background study subject/staff person had direct contact with persons served by the license holder’s program (personnel file numbered 10);

b. Documentation of orientation (personnel files numbered 1 and 8);

c. An annual job performance evaluation (personnel files numbered 4, 8, and 9);

d. An annual development and training plan (personnel files numbered 4, 5, and 7 through 10); and

e. Records of training and education activities that were completed during employment (personnel file numbered 8).

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

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

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

10. Violation: Four of five personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways:

a. The staff person did not receive orientation to the following prior to direct contact:

i. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 245A.65, subdivision 3, 626.557, and 626.5572, and all internal policies and procedures related to the prevention and reporting of vulnerable adults (personnel files numbered 1 and 8);

ii. The license holder’s program abuse prevention plan (PAPP) (personnel files numbered 1 through 3, 6, and 8);

iii. The child maltreatment reporting requirements in Minnesota Statutes, section 260E (personnel files numbered 1 and 8);

iv. Resident Rights (personnel files numbered 1 and 8);

v. Emergency procedures (personnel files numbered 1 and 8);

vi. Resiliency and recovery concepts and principles (personnel files numbered 1 and 8);

vii. Gender based needs (personnel files numbered 1 and 8);

viii. Resident confidentiality (personnel files numbered 1 and 8); and

ix. Training related to the specific activities and job functions that the staff person will be responsible to carry out (personnel files numbered 1, 2, 6, and 8); and

b. The staff person did not receive orientation to the following within 30 calendar days of direct contact (personnel files numbered 1 and 8):

i. Facility policies and procedures;

ii. Treatment needs of residents, including psychiatric disorders and co-occurring disorders; and

iii. Best practice service delivery including:

1. Trauma Informed Care;

2. Developmentally appropriate care;

3. The characteristics, and treatment of residents with special needs such as substance abuse, obsessive compulsive disorder, and eating disorders; and

4. Co-occurring disorders as defined by the population being served.

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

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of orientation training meets all applicable requirements. Within 45 days receipt of this order, submit training checklists related to the specific activities and job functions for clinical, supervisor, and administrative positions of the program to demonstrate compliance.

11. Violation: Five of five personnel files reviewed for requirements governing annual training did not meet requirements. The staff person did not receive training annually to the following:

a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 245A.65, subdivision 3, 626.557, and 626.5572, and all internal policies and procedures related to the prevention and reporting of vulnerable adults (personnel file numbered 8);

b. The license holder’s program abuse prevention plan (PAPP) (personnel files numbered 4, 5, and 7 through 10);

c. The child maltreatment reporting requirements in Minnesota Statutes, section 260E (personnel file numbered 8);

d. Resident rights (personnel files numbered 7 and 8);

e. Emergency procedures (personnel files numbered 7 and 8); and

f. Treatment services for residents with co-occurring disorders (personnel files numbered 4, 5, and 7 through 9).

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

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, 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 of annual training meets all applicable requirements.

Resident Files

12. Violation: Seven of seven resident files reviewed for requirements governing the Positive Support Rule did not meet requirements in the following ways:

a. The license holder did not provide written notice to the resident and their legal representative, at the time-of-service initiation or when the license holder changed the policy about the emergency use of manual restraint (EUMR), of the EUMR policy that included the resident’s rights under the PSR and Minnesota Statutes 245D.04 (resident files numbered 1 through 7); and

b. The Functional Behavior Assessment (FBA) did not meet requirements in the following ways (resident files numbered 3 and 4):

i. The FBA was not conducted by a qualified professional;

ii. Direct observation of the resident by the evaluator was not included; and

iii. The FBA did not include an evaluation of the following elements:

1. Biological factors, identified through a medical or dental assessment;

2. Psychological factors, identified through a diagnostic assessment or suicidality assessment;

3. Environmental factors, identified through direct observation or interviewing a significant individual in the person’s life; and

4. Quality of life indicators based on the person’s goals and needs within the domains of a meaningful life.

Rule Violated: Minnesota Rules, parts 9544.0040, subparts 1 and 3, and 9544.0080.

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, 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 of PSR meets all applicable requirements. Within 30 days receipt of this order, submit an FBA or an FBA template that demonstrates compliance.

13. Violation: One of four resident files reviewed for requirements governing program rules (resident file numbered 2) did not meet requirements. There was no documentation to demonstrate that the license holder communicated the program rules and details for the due process system used in the facility, both verbally and in writing, to the resident.

Rule Violated: Minnesota Variance, section R2960V.10.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

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

14. Violation: Seven of seven resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways:

a. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize safety risks (resident file numbered 6);

b. Treatment objectives were not measurable and did not include target dates for achievement (resident files numbered 1 through 3 and 5 through 7);

c. Strategy interventions did not identify the staff who were responsible to deliver the interventions (resident files numbered 1 through 3 and 5 through 7);

d. Strategy interventions did not identify the frequency they were to be implemented (resident files numbered 1 through 3 and 5 through 7)

e. Medication management treatment goals were not reflected on the plan (resident files numbered 1 through 3 and 5 through 7);

f. Individual support plans were developed late for individuals that displayed behaviors that required the use of restraint (resident files numbered 3 and 4); and

g. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (resident files numbered 1 through 3 and 5 through 7); and

h. The titles of the multidisciplinary team members were not included for those who completed and/or updated the plan of care (resident files numbered 1 through 3 and 5 through 7).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 1.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the individual plan of care meets all applicable requirements. Within 45 days receipt of this order, submit an individual plan of care for two residents that demonstrates compliance.

15. Violation: Two of seven resident files reviewed for requirements governing medication reconciliation and medication administration did not meet requirements in the following ways:

a. There was no documentation to demonstrate that a medication reconciliation was completed upon admission (resident file numbered 2); and

b. There was no notation on the resident’s medication administration record to indicate if the medication was administered as prescribed (resident file numbered 6).

Rule Violated: Minnesota Variance, section R2960V.08, subparts 3 and 4, item B.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

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

16. Violation: Seven of seven resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways:

a. The prescribing practitioner did not document a description in observable and measurable terms of the symptoms and behaviors the psychotropic medication is to alleviate (resident files numbered 1, 2, and 5 through 7);

b. The file did not contain documentation to demonstrate that the prescribing practitioner conducted and documented psychotropic medication reviews accordingly:

i. Weekly for the first month (resident file numbered 7); and

ii. Every month thereafter (resident files numbered 1 through 5); and

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

i. Targeted symptoms and behaviors of concern (resident files numbered 1 through 7);

ii. Data collected since the last review (resident filed numbered 3); and

iii. Side effects observed and actions taken (resident file numbered 6).

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

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure psychotropic medication reviews meet all applicable requirements. Within 45 days receipt of this order, submit psychotropic medication review documentation for two residents that demonstrates compliance.

17. Violation: Five of five resident files reviewed for requirements governing informed consent did not meet requirements in the following ways:

a. Informed consent was not obtained for an antipsychotic medication that was prescribed and administered to a resident (resident file numbered 5);

b. Documentation did not demonstrate the resident was informed and involved, if possible, in the decision making for each medication prescribed and administered (resident files numbered 5 and 6);

c. Informed consent documentation for prescribed psychotropic and antipsychotic medications did not contain the signature of the resident to acknowledge the prescribing practitioner or designee talked about the medication with the resident, answered questions, and that the resident agreed to the medication and dosage (resident files numbered 1, 2, 6, and 7).

Rule Violated: Minnesota Variance, section R2960V.08, subparts 7, item A, and 8.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

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

18. Violation: Seven of seven resident files reviewed for requirements governing medication side effect monitoring did not meet requirements in the following ways:

a. The license holder did not document and monitor for side effects within 24 hours of admission (resident files numbered 1, 2, and 7);

b. The license holder did not monitor for side effects weekly as determined by the prescribing psychiatric practitioner (resident files numbered 1 through 7); and

c. A standardized checklist or scale developed for a specific drug class as a monitoring tool was not identified for use as required by the prescribing psychiatric practitioner for residents prescribed antipsychotic medications (resident files numbered 1 through 7).

Rule Violated: Minnesota Variance, section R2960V.08, subparts 2, item G, and 10.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of medication side effects meet all applicable requirements. Within 45 days receipt of this order, submit the standardized checklist or scale that will be utilized to monitor the side effects for antipsychotic medications to demonstrate compliance.

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, you were previously found in violation of this same rule.

19. Violation: Two of two resident files reviewed for requirements governing the documentation of the use of restraint and seclusion did not meet requirements. The documentation did not demonstrate the following:

a. Prior events that may have been a contributing factor of the incident on July 27 and August 20, 2024 (resident file numbered 3) and on September 11 and October 26, 2024 (resident file numbered 4);

b. Why the supportive and less restrictive interventions failed or were found to be inappropriate on July 27 and August 7 and 20, 2024 (resident file numbered 3) and on September 11 and October 26, 2024 (resident file numbered 4); and

c. The types of interventions utilized including the type of physical holding used on September 11, 2024 (resident file numbered 4).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of use of restraint meets all applicable requirements. Within 45 days receipt of this order, submit a revised form or template for the documentation of uses of restraints to demonstrate compliance.

20. Violation: Two of two resident files reviewed for requirements governing debriefings following the use of restraint did not meet requirements in the following ways:

a. There was no documentation to demonstrate that a both debriefing sessions were conducted after the use of restraint for the following occurrences:

i. July 27 and August 7 and 20, 2024 (resident file numbered 3);

ii. September 11 and October 26, 2024 (resident file numbered 4); and

b. The debriefing documentation for incidents dated August 7 and 20, 2024 (resident file numbered 3) and September 11 and October 26, 2024 (resident file numbered 4) did not demonstrate the following

i. Whether any changes to the resident’s treatment plan or additional staff training resulted from the debriefings;

ii. Whether the license holder provided the resident with the opportunity to have a legal representative or advocate participate in the debriefing; and

iii. Whether the precipitating factors and alternative techniques that might have prevented the use of restraints were incorporated into the resident’s individual support plan to prevent future use.

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

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of debriefings meet all applicable requirements. Within 45 days receipt of this order, submit a revised form or template for the documentation of both staff and resident debriefing sessions that demonstrates compliance.

21. Violation: Two of two resident files reviewed for requirements governing administrative reviews of restrictive procedures did not meet requirements in the following ways:

a. There was no documentation to demonstrate an administrative review was completed for the use of restraint on July 27, 2024 (resident file numbered 3);

b. Documentation did not identify that the resident or the resident's representative had an opportunity to present evidence and argument to the reviewer about why the procedure was unwarranted, for the following uses of restraint:

i. August 7 and 20, 2024 (resident file numbered 3); and

ii. September 11 and October 26, 2024 (resident file numbered 4); and

c. The record of the administrative review for incidents dated August 7 and 20, 2024 (resident file numbered 3) and September 11 and October 26, 2024 (resident file numbered 4) did not include the following required components:

i. If the required documentation was recorded;

ii. If the restrictive procedure was used in accordance with the treatment plan;

iii. An evaluation of whether the rule standards governing the use of restrictive procedures were met; and

iv. Whether or not the staff who implemented the restrictive procedure were properly trained.

Rule Violated: Minnesota Variance, section R2960V.11, subpart 4.

Repeat Violation: Violations of this same requirement were previously found in Correction Orders that DHS issued on:

· July 25, 2024

· February 27, 2023

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of administrative reviews of restrictive interventions meet all applicable requirements. Within 45 days receipt of this order, submit a revised form or template for the documentation of administrative reviews that demonstrates compliance.

22. Violation: One resident file reviewed for requirements governing discharge and aftercare plans (resident file numbered 5) did not meet requirements in the following ways:

a. Documentation did not demonstrate that the discharge plan was developed at least 10 days before discharge;

b. The aftercare plan did not include the following:

i. Medication, dosage, and clinical rationale;

ii. Contact information for internal PRTF providers; and

iii. Contact information for the PRTF educational provider; and

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

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

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

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, you were previously found in violation of this same rule.

23. Violation: Three of seven resident files reviewed for requirements governing documentation standards did not meet requirements in the following ways:

a. Documentation in the resident’s file did not include the staff person’s titles (resident files numbered 1 through 7); and

b. Daily documentation did not include observations about the resident’s symptoms (resident files numbered 1, 2, and 7).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, item B, and R2960V.19, subparts 2 and 3.

Repeat Violation: In a Correction Order that DHS issued on July 25, 2024, you were previously found in violation of this same rule.

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

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

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

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

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

Questions

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

Sincerely,

Tina Christensen, Senior Licensor

Licensing Division

Office of Inspector General

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


state: MN

facility_name: Grafton Integrated Health Network Minnesota Psychiatric Residential Tr

raw_content:
July 25, 2024

Tony Sanders, Authorized Agent

Grafton Integrated Health Network Minnesota

3150 Shawnee Dr.

Winchester, VA 22601

License Number: 1109203 (PRTF)

Report Number: 202402238

CORRECTION ORDER

Dear Tony Sanders:

On April 1 through 5, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Grafton Integrated Health Network Minnesota, located at 224 Kray Mill Rd., Cold Spring, MN 56320. This review was conducted to determine compliance with state and federal laws and rules governing the provision of psychiatric residential treatment facilities under the variance to Minnesota Rules, Chapter 2960; R2960V. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Postings, Policies, and Practices

1. Violation: The license holder did not comply with posting requirements in the following ways:

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

b. A copy of the resident’s rights was not posted where it could be readily accessed by staff and residents.

Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and Minnesota Variance R2960V.04, subpart 2, item B.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure postings meet all applicable requirements. This was corrected onsite, no further action required.

2. Violation: The license holder did not meet requirements governing the program’s access to a licensed mental health professional. The license holder did not maintain a current schedule of the available licensed mental health professionals to ensure a treatment staff’s access, either in person or by telephone, to a licensed mental health professional within 30 minutes.

Rule Violated: Minnesota Variance, section R2960V.14, subpart 4.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the program’s access to a licensed mental health professional meet all applicable requirements. This was corrected onsite, no further action required.

3. Violation: The license holder did not meet requirements of Minnesota Rules, chapter 9544, the Positive Supports Rule (PSR), in the following ways:

a. The license holder’s policy, Program Rules OPS 130, and the Resident Handbook allowed for the use of time-out, a prohibited procedure; and

b. The license holder did not develop policies and procedures to maintain compliance with the PSR. The license holder’s policies and procedures did not address the requirements of the PSR in the following ways:

i. The license holder did not have a procedure to screen for and determine who qualifies for the PSR;

ii. The license holder did not have a policy on the emergency use of manual restraint, for notifying a resident and their legal representative of the policy and the resident’s rights;

iii. The license holder did not have a policy or procedure requiring that a positive support transition plan will be developed for a resident who has had either three incidents of emergency use of manual restraint within 90 days or four incidents of emergency use of manual restraint within 180 days; and

iv. The license holder’s policies did not include the following in accordance with the standards identified in Minnesota Rules, chapter 9544:

1. Procedures for conducting functional behavioral assessments;

2. The prohibited and permitted use of procedures and restrictions;

3. Procedures for implementing and documenting the required positive support strategies and person-centered planning; and

4. Procedures for reporting the use of restrictive interventions and incidents to the commissioner on the behavior intervention report form required by the commissioner.

Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 14; Minnesota Rules, parts 9544.0010, subpart 2, 9544.0030 through 9544.0080, 9544.0100, and 9544.0110; and Minnesota Variance, sections R2960V.02, subpart 1, and R2960V.10.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of Positive Support Rule (PSR) meets all applicable requirements. Within 30 days receipt of this order, submit policies and procedures for the PSR areas identified above to demonstrate compliance.

4. Violation: The license holder did not provide the commissioner with timely and complete access to resident files, personnel files, and other documentation required to demonstrate compliance with applicable statutes and rules. The commissioner must be given access without prior notice and as often as the commissioner considers necessary if the commissioner is conducting a licensing inspection.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 5.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the commissioner’s right of access meet all applicable requirements.

5. Violation: The license holder did not meet requirements governing staff ratios. Documentation did not demonstrate:

a. If at least one staff person to every three residents present within the living unit was scheduled during awake hours; and

b. If at least one staff person to every six residents present within the living unit was scheduled during sleeping hours and if there was access to other staff persons available within the facility.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of staff ratios meet all applicable requirements. Within 30 days receipt of this order, submit two consecutive weeks of unit staff schedules and the corresponding daily resident census per each living unit to demonstrate compliance.

6. Violation: The license holder did not meet requirements governing clinical supervision. For three of three weeks reviewed, the license holder did not ensure all treatment team members participated either in clinical supervision or an ancillary meeting for each calendar week they worked, for the weeks of:

a. December 24, 2023 (11 of 44 staff persons);

b. March 3, 2024 (7 of 38 staff persons); and

c. March 10, 2024 (11 of 38 staff persons).

Rule Violated: Minnesota Variance, section R2960V.13.

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

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

7. Violation: The license holder failed to ensure that all PRTF service staff in regular contact with residents were aware and understood each resident’s needs, goals, and services identified in the residents’ plan of care. During the licensing review, DHS licensors received information indicating that staff persons did not know how to implement interventions identified in resident plans of care.

Rule Violated: Minnesota Variance, section R2960V.06, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the that all PRTF service staff in regular contact with residents are aware and understand each resident’s needs, goals, and services identified in the residents’ plan of care.

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

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

i. Resident outcomes, including identifying ways to improve effectiveness of the services provided to residents and to improve resident outcomes;

ii. Restraint data, according to part R2960V.11;

iii. Serious occurrences and other significant incidents, including:

1. Determining whether policies and procedures were followed;

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

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

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

iv. Self-monitoring of compliance, including evaluating compliance with the requirements of the PRTF Variance, R2960V, and demonstrating action to improve the program’s compliance with the requirements; and

b. The license holder did not at least annually review, evaluate, and update the quality assurance and improvement plan required to include documentation of the actions the license holder would take as a result of the information obtained from the monitoring activities outlined in the plan and goals to improve service delivery for the next year.

Rule Violated: Minnesota Variance, section R2960V.17, subparts 1 and 2.

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

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

9. Violation: The license holder did not complete a quarterly review of the patterns of the use of restraint procedures that considered the following:

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

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

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

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

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

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

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

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

10. Violation: The license holder’s governing body did not annually review the Program Abuse Prevention Plan (PAPP) using the assessment factors in the plan and any substantiated maltreatment findings that occurred since the last review for calendar years 2022 and 2023.

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

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

11. Violation: A controlling individual of the program did not annually review and sign the plan for transfer of clients and records upon closure for calendar years 2022 and 2023.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual review of the plan for transfer of clients and records upon closure meet all applicable requirements.

Personnel Files

12. Violation: Five of five personnel files reviewed for requirements governing training for staff providing services to individuals who qualify for the Positive Support Rule (PSR) did not meet requirements. Documentation did not demonstrate the following:

a. Whether the following training was completed:

i. At least eight hours of core training, for staff persons responsible for developing, implementing, monitoring, supervising, and/or evaluating positive support strategies, a positive support transition plan, and/or the emergency use of manual restraint, to the following required topics (SP1 through SP5):

1. Principles of person-centered service planning and delivery, and how they apply to direct support services provided by staff;

2. The safe and correct use of manual restraint on an emergency basis;

3. Staff responsibilities related to prohibited procedures; why the procedures are not effective for reducing or eliminating symptoms or interfering behavior; and why the procedures are not safe;

4. Staff responsibilities related to restricted and permitted actions and;

5. The procedures and forms staff must use to monitor and report use of restrictive interventions that are part of a positive support transition plan;

6. Understanding of the person as a unique individual and how to implement treatment plans and responsibilities assigned to the license holder; and

7. Personal staff accountability and staff self-care after emergencies;

b. An additional four hours of function-specific training based upon the level of responsibility and qualifications, prior to assuming responsibilities, for staff persons who develop positive support strategies and program managers, to the following required topics (SP4 and SP5):

i. Functional behavior assessments;

ii. How to apply person-centered planning;

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

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

c. A minimum of an additional two hours of function-specific training for staff persons in manager positions to the following required topics (SP4 and SP5):

i. How to include staff in organizational decisions;

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

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

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

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

13. Violation: Five of five personnel files reviewed for requirements governing background study subjects and staff files did not meet requirements. The files did not include:

a. Verification of the staff persons qualifications specific to the position including required credentials and/or professional licensure (SP5);

b. The date of hire (SP2 through SP4);

c. Job description (SP1 and SP3 through SP5);

d. The date the background study subject/staff person had direct contact with persons served by the license holder’s program (SP2 and SP5);

e. An annual job performance evaluation (SP5); and

f. An annual development and training plan (SP5).

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

Repeat Violation: The license holder was cited for a similar violation in the following orders:

· Correction Order dated May 5, 2023

· Correction Order dated February 27, 2023

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

14. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements. The staff person did not receive orientation to the following prior to direct contact (SP2 through SP4):

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

b. Training related to the specific activities and job functions that the staff person will be responsible to carry out.

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

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

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

15. Violation: Two of two personnel files reviewed for requirements governing annual training did not meet requirements. The staff person did not receive annual training to the following:

a. The vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, section 245A.65, subdivision 3, and 626.557 and 626.5572, and the license holder’s program abuse prevention plan (PAPP) (SP1 and SP5); and

b. Resident behavioral emergency procedures (SP1); and

c. Treatment services for residents with co-occurring disorders (SP1 and SP5).

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

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

16. Violation: Five of five personnel files reviewed for requirements governing documentation of orientation and training (SP1 through SP5) did not meet requirements. Documentation did not include names and credentials of the people who certified the completion of the training.

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

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

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

Resident Files

17. Violation: Two of two resident files reviewed for requirements governing the Positive Support Rule did not meet requirements in the following ways:

a. The license holder utilized a prohibited action and/or procedure for a behavioral or therapeutic program to reduce or eliminate a behavior in the following ways:

i. Use of a show of force on November 26, 2023 (R3);

ii. Use of an intervention that constituted an aversive or deprivation procedure on March 2, 2024 (R1); and

iii. Use of time-out on December 7, 25, and 26, 2023, and January 9, 10, and 12, 2024 (R3);

b. The license holder did not use the behavior intervention report form (BIRF) required by the commissioner to report the following incidents to the commissioner:

i. An emergency use of manual restraint on March 23 and 31, 2024 (R1) and on January 13, 2024 (R3); and

ii. A behavioral incident that resulted in a call to 911 on February 25, 2024 (R1) and on November 26, 2023 (R3).

Rule Violated: Minnesota Rules, parts 9544.0060, subpart 1 and 9544.0110; and Minnesota Variance, section R2960V.02, subpart 1.

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

18. Violation: Three of three resident files reviewed for requirements governing resident rights (R1 through R3) did not meet requirements. Documentation of the resident’s receipt of basic rights information did not demonstrate that the license holder explained the rights to the resident in a language that the resident could understand and upon the time of admission.

Rule Violated: Minnesota Variance, section R2960V.04, subpart 2, item A.

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

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

19. Violation: Three of three resident files reviewed for requirements governing program rules (R1 through R3) did not meet requirements. Documentation did not demonstrate that the license holder communicated the program rules and details for the due process system used in the facility, both verbally and in writing, to the resident.

Rule Violated: Minnesota Variance, section R2960V.10.

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

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

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

a. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize safety risks (R1 through R3);

b. The plan of care was not reviewed at least once during the first 10 days following admission (R2 and R3);

c. Treatment objectives were not measurable and did not include target dates for achievement (R1 through R3);

d. Strategy interventions did not identify the staff who were responsible to deliver the interventions (R1 through R3);

e. Strategy interventions did not identify the frequency they were to be implemented (R1 through R3)

f. Medication management treatment goals were not reflected on the plan (R1 through R3);

g. There was no documentation to demonstrate an individual support plan was developed for individuals that displayed behaviors that might require the use of restraint or seclusion (R1 through R3); and

h. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (R1 and R3).

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

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

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

21. Violation: Three of three resident files reviewed for requirements governing medication reconciliation and medication administration did not meet requirements in the following ways:

a. Medication reconciliation was not completed upon admission (R1 through R3) and upon discharge (R3). Documentation did not demonstrate the following process was followed:

i. A list of current medications was developed, including the dose and frequency along with other drug interactions and allergies from the residents last residence or hospitalization;

ii. Prescriptions or admission orders were compared to the current medication list and any discrepancies were identified, and any differences were reconciled;

iii. The prescriber was notified of any discrepancies so the prescriber could make clinical decisions based on the comparison;

iv. If required, new orders were obtained; and

b. The medication administration record included blank time entries and there was no notation to indicate if the medication was administered as prescribed (R1 through R3); and

c. There was no documentation in the file to demonstrate the quantity of medications initially received from the pharmacy (R1 through R3).

Rule Violated: Minnesota Variance, section R2960V.08, subparts 3, and 4, items A through C.

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

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

22. Violation: Three of three resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways (R1 through R3):

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

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

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

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

i. Targeted symptoms and behaviors of concern;

ii. Data collected since the last review; and

iii. Side effects observed and actions taken.

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

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

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

23. Violation: Two of three resident files reviewed for requirements governing informed consent did not meet requirements in the following ways:

a. The license holder did not obtain informed consent, either orally or in writing, prior to the administration of a psychotropic medication (R1 and R3);

b. The license holder did not obtain informed consent, in writing only, prior to the administration of an antipsychotic medication. Requirements were not met in the following ways:

i. The informed consent was not signed by the legal representative (R2);

ii. There was no informed consent form in the file for an antipsychotic medication that was administered to a resident (R3); and

iii. A medication was administered on June 15, 2023, prior to informed consent provided by the legal representative for authorization on September 22, 2023 (R3);

c. Documentation did not demonstrate if the resident was informed and involved, if possible, in the decision making for each medication prescribed and administered (R1 through R3);

d. Informed consent was not obtained by the license holder within 30 days to continue the use of psychotropic medication for a resident admitted with prescribed psychotropic medication (R1 and R3);

e. Informed consent documentation for prescribed psychotropic and antipsychotic medications did not contain the following required information:

i. The diagnosis for which the medication was prescribed (R3);

ii. The pharmacological and non-pharmacological treatment options available and the course of the condition with and without the treatment options (R3);

iii. Specific information about the psychotropic medication to be used, including (R3):

1. The route of administration;

2. The estimated duration of therapy; and

3. The possible dosage range or maximum dose;

iv. How the serious risks and possible side effects of the medication must be managed (R3);

v. An explanation that consent may be refused or withdrawn at any time and that the consent is time-limited and automatically expires within 30 days for oral consent and yearly for written consent (R3);

vi. The names, addresses, and telephone numbers of appropriate professionals to contact if questions or concerns arise (R3); and

vii. The signature of the resident to acknowledge the prescribing practitioner or designee talked about the medication with the resident, answered questions, and that the resident agreed to the medication and dosage (R1 through R3).

Rule Violated: Minnesota Variance, section R2960V.08, subpart 7, items A and E, and subpart 8.

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

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

24. Violation: Three of three resident files reviewed for requirements governing medication side effect monitoring did not meet requirements in the following ways (R1 through R3):

a. The license holder did not document and monitor for side effects within 24 hours of admission;

b. The license holder did not monitor for side effects weekly as determined by the prescribing psychiatric practitioner; and

c. Standardized checklists, rating scales, or scales developed for a specific drug or drug class were not used as monitoring tools as determined by the prescribing psychiatric practitioner.

Rule Violated: Minnesota Variance, section R2960V.08, subparts 2, item G, and 10.

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

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

a. Staff debriefing sessions were not conducted after the use of restraints for the following occurrences:

i. March 23 and 31, 2024 (R1); and

ii. January 24, 2024 (R3); and

b. Precipitating factors and alternative techniques that might have prevented the use of restraints

were not incorporated into the resident’s individual support plan to prevent future use (R1 and R3).

Rule Violated: Minnesota Variance, section R2960V.11, subpart 3, items A and C.

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

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

26. Violation: Two of two resident files reviewed for requirements governing administrative reviews 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

incident dates:

i. March 23 and 31, 2024 (R1); and

ii. January 13, 2024 (R3);

b. The administrative review was not completed by someone other than the person who decided to impose the restraint, or that person’s immediate supervisor for the use of restrictive procedures on January 13, 2024 (R3);

c. Documentation did not identify that the resident or the resident's representative had an opportunity to present evidence and argument to the reviewer about why the procedure was unwarranted, for the following incidents:

i. March 23 and 31, 2024 (R1); and

ii. January 13, 2024 (R3); and

d. The record of the administrative review for incidents dated March 23 and 31, 2024 (R1) and January 13, 2024 (R3) did not include the following required components:

i. If the required documentation was recorded;

ii. If the restrictive procedure was used in accordance with the treatment plan;

iii. An evaluation of whether the rule standards governing the use of restrictive procedures were met; and

iv. Whether or not the staff who implemented the restrictive procedure were properly trained.

Rule Violated: Minnesota Variance, section R2960V.11, subpart 4.

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

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

27. Violation: One resident file reviewed for requirements governing discharge and aftercare plans (R3) did not meet requirements in the following ways:

a. Documentation did not demonstrate that the discharge plan was developed at least 10 days before discharge;

b. The aftercare plan did not include the following:

i. Medical needs;

ii. Discharge diagnosis;

iii. Appointments with after discharge service providers indicating date, time, and place;

iv. Contact information for internal PRTF providers;

v. Contact information for the PRTF educational provider; and

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

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

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

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

a. Documentation in the resident’s file did not include direct care and nursing staff person’s titles (R1 through R3);

b. A mental health professional did not co-sign and date required treatment service notes for a clinical trainee who provided treatment services to a resident on February 8 and 21, 2024 and March 6, 7, and 8, 2024 (R2);

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

i. February 22, 2024, and March 3, 4, 5, and 9, 2024 (R1); and

ii. December 12, 2023, and January 4, 5, 14, 17, and 19, 2024 (R3); and

d. Documentation did not demonstrate case coordination activities occurred with other professionals, including case managers and community-based mental health providers, or others (R1 & R2).

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

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

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

29. Violation: One resident file reviewed for requirements governing the no eject policy (R3) did not meet requirements. Documentation did not demonstrate:

a. Whether the license holder conferred with all interested persons to review the issues involved in the decision to discharge the resident; and

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

c. Any alternatives considered or attempted.

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

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

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

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

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

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

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

Questions

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

Sincerely,

Tina Christensen, Senior Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


raw_content:
May 5, 2023

Tony Sanders, Authorized Agent

Grafton Integrated Health Network

3150 Shawnee Dr.

Winchester, VA 22601

License Number: 1109203 (PRTF)

Investigation Report Number: 202302221

CORRECTION ORDER

Dear Tony Sanders:

A licensing investigation of Grafton Integrated Health Network Minnesota Psychiatric Residential Treatment Facility, located at 224 Kray Mill Rd., Cold Spring, MN 56320, was conducted to determine compliance with state and federal laws and the variance governing Psychiatric Residential Treatment Facilities (PRTF) under Minnesota Rules, part R2960V. As a result of this licensing investigation a Correction Order is being issued.

A. Reason for Correction Order

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

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

Personnel File

1. Citation: Minnesota Variance, section R2960V.15, subpart 5.

Violation: One personnel filed was reviewed for requirements governing staff files (SP1) and did not meet requirements. The file did not include verification of the staff persons qualifications to the position including required credentials and/or professional licensure.

SP1 was hired on February 6, 2023 as a Therapist I with job responsibilities that included, but not limited to, psychotherapy and treatment plan development as a license eligible practitioner under clinical supervision. SP1 was not license eligible and therefore not qualified to provide treatment services.

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

Repeat Violation: The license holder was cited for a similar violation in correction order dated February 27, 2023.

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.

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 Ginny Benson, Human Services Licensor at 651-431-9657, as soon as possible

Ginny Benson, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

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