facility_name: Bar None Residential Services

report_date: February 15, 2023

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

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

Report Number: 202210107

Date Issued: February 15, 2023

Name and Address of Facility Investigated:

Bar None Residential Services
22426 Saint Francis Blvd
Anoka, MN 55303

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

License Number and Program Type:

1036848-CRF (Children’s Residential Facility)

Investigator(s):

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

651-431-6572

Suspected Maltreatment Reported:

It was reported that staff persons (SP1-SP3) used a physical hold on an alleged victim (AV) that included a “choke hold,” throwing the AV to the floor, and calling the AV “bitch.”

Date of Incident(s): December 5, 2022

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 site visit conducted on December 19, 2022; from documentation and video footage at the facility; and through ten interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1, SP3, and P1-P3), and supervisory staff persons (P4-P6). Facility youth (Y1 and Y2) also provided information, which was included in this report. SP2 initially responded to this investigator’s request for an interview, but then did not respond at the scheduled interview time or to subsequent requests.

The AV’s support plans provided the following information:

· In October 2022, the AV moved into the facility’s shelter unit where s/he was expected to remain until there was an opening in the facility’s mental health services and treatment unit.

· The AV was 15 years old and his/her diagnoses included reactive attachment disorder, attention-deficit hyperactivity disorder, and fetal alcohol syndrome.

· The AV had a history of mental health symptoms, including anxiety and anger management difficulties, which created vulnerabilities for him/herself. “Unit staff will be briefed on [the AV’s] history of mental health symptoms and will provide support such as increased supervision or additional check-ins as needed. Unit staff will offer and encourage [the AV] to utilize coping skills when [s/he] is experiencing difficult emotions.”

· The AV had a history of being abused by others, and was a trauma survivor. “Unit staff will be made aware of and be sensitive to [the AV’s] trauma history and will work to create a secure and safe environment for [him/her] where [his/her] needs will be met. Staff will monitor [the AV’s] interactions with peers and teach effective interactions with others. Staff will encourage the use of coping skills to manage any symptoms of trauma.”

· The AV had a history of aggression towards others. “Unit staff will be briefed on this history and will work to intervene as appropriate. Staff will closely monitor [the AV’s] interactions with others. Staff will offer redirections, breaks, timeouts, or physical escorts in the event that [the AV] is showing signs of aggression or escalation.”

According to the facility’s website, www.voamnwi.org, the facility provided temporary shelter care and behavior stabilization services for adolescents ages 12-17.

Within the shelter unit, there were youth bedrooms, common areas, and a staff office. The staff office door opened into a short hallway that connected a dayroom area to a dining room. The office walls were made almost entirely of glass allowing increased visibility in and out. There was a camera (camera #1) facing the area that included visuals of the dayroom, hallway, and office. There was a second camera (camera #2) on the other side of the office capturing 360 degrees (°) of the dining room, and portions of the office and hallway. The cameras

recorded activity, but not audio. [Note: Camera #2 was not dated or timestamped; camera #1 was. Both cameras were smudged in various areas on the lens making visibility difficult.]

The AV stated that on December 5, 2022, s/he had just finished a phone call that was “not good.” The AV asked SP3 if s/he could “take a break,” and SP3 told the AV to ask SP1. (Based on the AV’s description, SP1 was close by and/or within earshot of this conversation.) SP1 responded, “Fuck that. Piece of shit. I’ll kill [the AV] and [the AV’s] whole family.” The AV then “threw something” at SP1. SP1 responded by “tackling” the AV, “choking [the AV’s] face,” punching the AV, and pulling the AV’s hair. SP1 repeatedly stated that s/he was going to “kill” the AV and that the AV was “a piece of shit.” Other than these statements, no other staff were talking or giving any directives to the AV. The AV struggled against SP1’s actions, but did not punch at, or strike, SP1. After about “15 or 20 minutes,” the staff let go of the AV. The AV was not injured during the incident.

P1 watched camera footage of the aforementioned incident and had concerns about what s/he observed. “The video was very telling.” P1 stated that SP1 had the AV in a “choke hold,” and “slammed” the AV onto the floor. SP3 then grabbed both of the AV’s legs and “slam[med]” them onto the floor.

P2 did not watch the camera footage, but said that about two hours prior to the incident with the AV, s/he saw SP1 yelling and swearing, saying “Fuck this place,” while in the presence of the youth.

Y1’s bedroom was near the staff office. During the incident, Y1 poked his/her head out of his/her door and observed about five to six seconds, which included staff holding the AV to the floor. Y1 also heard SP1 call the AV, “bitch,” and might have heard something similar to threatening the AV and the AV’s family.

Y2 also observed portions of the incident, and said that s/he saw SP1 put the AV “in a head lock and was punching [the AV] on the back of [his/her] head.”

The FM said that the AV had a history of repeatedly “poking” at staff to get a reaction, and then “playing the victim” if the staff reacted; and if the staff did not react, then the AV assaulted them. That said, the FM understood that there might be an exception in any situation. The FM was not present for the aforementioned incident and therefore did not know exactly what happened.

The facility’s camera footage showed the following:

Dec. 5, 2022

6:41:56 PM – 6:42:01 PM

Camera #1 – The AV entered the hallway, walking towards the staff office, carrying a flower pot. [Note: Information was provided that the flower pot was made of “thick plastic” with a “fake” plant inside.] The AV stopped outside the office door, which was propped open, stepped through the threshold, and threw the flower pot at SP1, who was standing directly inside the door. (Information obtained was that SP2 was also inside the office, but not visible.) The video did not show if SP1 was struck by the flower pot.

6:42:02 PM –

6:42:03 PM

Camera #1 – The AV stepped out of the threshold and turned as though s/he intended to walk back down the hallway. Almost simultaneously, SP1 stepped out of the office and placed both of his/her hands on the AV’s shoulders.

6:42:04 PM – 6:42:08 PM

Camera #1 – The AV raised his/her hands and placed them near SP1’s hands. The two moved abruptly back and forth while facing each other. SP2 placed his/her hands on the AV’s back. SP1 pulled the AV towards the opposite side of the hallway. SP2 appeared to lose hold of the AV. The AV’s back hit the wall. The AV slumped forward. SP1 pulled the AV towards him/her while simultaneously turning away from the AV, which caused them to both be facing the camera with the AV bent down behind and to the right of SP1.

6:42:10 PM

Camera #1 – SP1’s right arm appeared to be around the AV’s head or neck. SP1’s left arm was visible in front of his/her body, bent, and appearing to touch the AV’s head. SP2 continued to grab at the AV, but repeatedly lost hold when SP1 and the AV abruptly moved around.

6:42:13 PM – 6:42:18 PM

Camera #1 – SP1 turned towards the AV so that the AV was between SP1 and SP2, facing SP1. SP2 grabbed the AV from behind while SP1 was bent forward grabbing at the AV’s thighs. The AV stumbled forward and SP2 appeared to lose his/her grip on the AV’s back. SP1, while remaining bent over in front of the AV, jumped forward and the AV went down to the floor on his/her back with SP1’s head around the AV’s midsection.

Camera #2 – The AV and SP1 fell to the floor with SP1 landing on top of the AV. SP1 then scooted upward on the AV’s body, so that SP1’s arms were wrapped around the AV’s upper back, neck, and/or head area. The AV’s head was pressed into SP1’s chest or underarm area. SP1 appeared to be speaking to the AV and/or SP2. The AV appeared to momentarily struggle at various points but also appeared to have limited movement capabilities due to SP1 lying on top of him/her. SP2 stood over them.

6:42:20 PM – 6:42:38 PM

Camera #2 – The AV while still under SP1 swung his/her left arm hitting SP1’s right side of torso and right side of head. SP2 then bent down and appeared to hold the AV’s arm.

6:42:38 PM –

6:43:40 PM

Camera #1 – The camera recording jumped from 6:42:38 PM to 6:43:40 PM. At this point, SP2 was bent down on one knee and appeared to have his/her hands around the midsection of the AV and/or SP1. The AV and SP1 did not appear to be moving. (Information was provided that the camera only recorded when it detected movement. If movement was not detected, the camera did not record, which explained the lapse in footage. Information was also provided that at some point SP1 and SP2 flipped the AV over so that s/he was face-down on the floor; however, it was not clear on the video when this occurred.)

6:43:49 PM –

6:44:05 PM

Camera #1 – SP3 entered the dayroom walking towards the scene.

Camera #2 – SP2 was squatted down next to the AV and SP1, who remained lying on the floor and did not appear to be moving.

6:44:05 PM –

6:44:10 PM

Camera #1 – SP3 bent down and picked the AV’s legs off of the floor, stepped towards the AV, and then dropped to his/her knees while holding the AV’s legs on either side of SP3’s torso. SP3 then appeared to lay down on top of the AV’s legs. At this point, there was undetermined movement, whether by SP1, SP3, and/or the AV.

6:44:15 PM

Camera #1 – P3 entered the dayroom walking towards the scene. SP3 sat up and was no longer lying on the AV’s legs. P3 stood near them in the hallway, and did not make any physical contact with the AV or staff persons.

Camera #2 – SP2 remained squatted down next to AV and SP1, who remained lying on the floor and did not appear to be moving. SP3 was squatted by the lower portion of the AV’s legs.

6:44:23 PM – 6:46:41 PM

Camera #1 – At this point, it appeared SP1, SP2, and SP3 were each kneeling over the AV, who was lying on the floor. P3 was standing nearby watching. The AV did not appear to be moving during this time.

6:46:41 PM –

6:50:34 PM

Camera #1 – The camera recording then jumped from 6:46:41 PM to 6:50:18 PM. At this point, the AV was standing up and walking away. SP1, SP3, and P3 were also standing, and SP2 was sitting on the floor. The video footage then ended.

On December 5, 2022, following the aforementioned incident, the AV submitted an Official Grievance Form to the facility, and included the following:

“[SP1] told me [s/he] would kill me and my family and when [SP1] brot [sic] me to the growund [sic] [SP3 and SP1] repetle [sic] cald [sic] me names and screamd [sic] obsides [sic] at me [Y1] winessed [sic] them and heard them call me names. [SP1] also puld [sic] my hiar [sic]. i was scaryd [sic] for my life”

On December 8, 2022, P4 documented the “Disposition of the Grievance” on the AV’s Official Grievance Form, and included the following:

“[SP1, SP2, and SP3] explained that [the AV] was not following expectations that afternoon into the evening. [The AV] was calling staff names and threatening them. [The AV] threw objects … and hit staff. [The AV] was placed in a hold so [s/he] would not throw any more objects or hurt anyone. There was a lot of yelling at each other.”

“[SP1, SP2, and SP3 were] talked to on how not to let what residents say effect [sic] them. They should ignore negative comments. Yes, they need to protect themselves but remain calm. Staff will be using de-escalation more.”

SP1 provided the following information:

· Immediately prior to the incident, the AV had asked to take a “break” or a walk with staff. SP1 declined, citing the AV’s prior maladaptive behavior (i.e. throwing the unit telephone in a garbage can). The AV responded by picking up the garbage can and dumping the contents on the office floor. The AV then walked away towards his/her bedroom.

· Shortly after, the AV returned to the office carrying a hairbrush and a flower pot. The AV threw both items at SP1 striking SP1’s back. SP1 said, “I just went out there (into the hallway) and there was another staff (SP2) and we just went out there and we was like trying to grab [the AV] but like it was two staff so like we both didn’t really know what like hold we was trying to put [him/her] in and then so I just kinda like grabbed [him/her] like this and we fell.” SP1 demonstrated wrapping his/her arms around in a hugging motion and described the action as “like a bear hug.”

· “I fell on top of [the AV] and then probably 10-15 seconds after, we finally turned [him/her] around and then I just had [his/her] hands like this.” SP1 demonstrated having the AV’s hands resting on the AV’s lower back, palms up, with one on top of the other. SP1 believed they remained in this position for about two minutes.

· When this investigator referred to SP1’s conduct as being a “hold,” SP1 said, “It wasn’t a hold cause I didn’t like actually put [him/her] in a hold. I was just holding [his/her] hands like this while talking to [him/her] … I didn’t put [him/her] in a hold.” SP1 demonstrated having the AV’s hands resting on the AV’s lower back, palms up, with one on top of the other.

· When this investigator asked for clarification on why SP1 did not believe his/her conduct was a “hold,” SP1 said, “I mean like. I wasn’t like mad, like I wasn’t like. I didn’t put [him/her] in a hold cause [s/he] was calm. After like I had [him/her] on. Like after we fell, and I had [him/her] like this, and we finally flipped [him/her] over, [s/he] was calm and so I didn’t see no reason to put [him/her] in like a hold so we just had [his/her] hand on [his/her] back like this and [s/he] was just resting and laying down.”

· SP1 said that s/he initiated physical contact with the AV because the AV had just thrown a hairbrush and a flowerpot at him/her. “I don’t know about you, but that’s a hold. At Bar None or anywhere else that I’ve worked at, that’s a hold if someone is throwing stuff at you. So, that’s what prompted it.”

· SP1 said s/he did not say anything to the AV during the incident and that no other staff persons said anything to the AV either.

· SP1 said that s/he was trained to provide redirection prior to implementing a hold and, “Yeah, [the AV] had. The whole. This is like a whole weeks of verbal redirection. It’s not like we just put [him/her] in a hold. [S/he] already threw apples at our cars. [S/he] already cursed us out every single day. [S/he] already [unintelligible] every single day we come in. It wasn’t like. I ain’t never even put a kid in a hold since probably seven months. Since that. But, it wasn’t like this just happened. It was like a daily thing where like redirection, redirection, redirection, and that same day when [s/he] threw the phone in the trash, it wasn’t like, ‘Oh you’re going to get put in a hold.’ I was wiping it. I didn’t even talk to [his/her] ass and then [s/he] threw the trash all over the office. Nobody said nothing. Nobody put [him/her] in a hold. Nothing. It’s just the fact that [s/he] came back with a brush and flower pot and threw it at me. That’s physical abuse. So I have a right to put [him/her] in a hold at that point. So [s/he] got put in a hold.”

· SP1 denied having done and did not witness others, place the AV in a choke hold, call the AV names, or threaten the AV.

· SP1 said that s/he received training on the facility’s restrictive procedures, including physical holds.

SP3 provided the following information

· SP3 left the unit prior to the start of the incident. When s/he returned, SP1 and SP2 had the AV in a physical hold and the AV was “Just laying [sic] there.” “I grabbed [the AV’s] legs until [s/he] was ready to get up.”

· The AV was “not really” struggling or fighting back against the hold, but SP3 grabbed the AV’s legs because, “It’s part of our procedure,” even when a youth was not doing anything.

· SP3 did not know if SP1 and/or SP2 were giving the AV any instructions or redirection, because SP3 was wearing “air pods” at the time and could not hear.

· SP3 said that s/he did not, and did not witness others, place the AV in a choke hold, call the AV names, or threaten the AV.

· SP3 said that s/he received training on the facility’s restrictive procedures, including physical holds.

P3 provided the following information:

· P3 told this investigator that the AV had a history of being “disrespectful towards the staff” and “curses 24/7.” Staff gave the AV “paperwork” as a consequence for his/her maladaptive behaviors, but then the AV would go to a supervisor and they would “overturn” the paperwork giving the AV “power.” P3 said, “There’s nothing we can do … If we can’t give [the AV] paperwork, we have to put [him/her] in a hold.”

· P3 was not present when the hold was initiated, but stated that s/he did not have concerns regarding the portion of the hold that s/he did witness. P3 said that if a youth threw something at staff it would “not necessarily warrant a hold,” but “it depends … everyone is different.” P3 did not witness any staff place the AV in a chokehold, call the AV names, or threaten the AV.

P4-P6 provided the following information:

· P5 watched the aforementioned camera footage, and said, “The technique [used to hold the AV] did not align with what we train on … No hold is ever going to be just like the manual.” P5 had been working in his/her position for many years, and had reviewed several incidents involving physical holds. P5 reiterated that most physical holds did not look like they did in the training. “Doesn’t always happen the way they are trained.”

· P6 said that the physical hold “was not the way we train on a hold.” In watching the aforementioned camera footage, P6 said that it looked like SP1 had initially been attempting to escort the AV to the calming room; however, the AV got turned around and when SP1 “bear-hugged” the AV to get him/her turned back around, they both fell to the floor.

· P4 said, “The hold was very sloppy.”

· P4-P6 each did not observe any staff use a choke hold on the AV, and the AV did not disclose such information during subsequent, separate, interviews with P4 and P6.

· P4 interviewed the AV for the facility’s internal investigation, and, “[The AV] kept changing [his/her] story.” At one point, the AV said that SP1 called him/her, “bitch,” and that SP1 threatened to hurt the AV; however, the AV then “changed [his/her] story” so that SP1 did not threaten him/her.

· P6 said that s/he was not initially told about any name-calling, but that a few days after the incident, the AV told him/her that SP1 had been calling him/her names and threatened him/her.

· P5 said that if a youth threw an object at staff, it might warrant a physical hold if lesser methods of de-escalation were unsuccessful. The AV had a potential to assault other staff persons and/or other youth, and because of this, intervention was necessary. A hold was used if de-escalation was not successful. P5 believed that, regarding the incident herein, SP2 tried using verbal redirection following the AV’s “bad” phone call; however, was unsuccessful. P5 added that throwing objects had a potential to be charged as an assault by a law enforcement agency, and that this might also require physical intervention by staff.

· P6 said that the AV had a history of being “impulsive,” and knowing that the AV had just thrown a flower pot at staff, P6 believed the staff were warranted in implementing a physical hold. There were other flower pots on the unit, which the AV could have continued to throw at staff.

· P4 said that throwing an object at a staff person might warrant a hold, but it “depends on how extreme.” However, the AV’s conduct of throwing a flower pot at SP1 would “definitely” warrant an escort to the calming room, which, according to P4’s observations of the camera footage, was what it looked like SP1 was attempting to do.

· P6 said that regarding SP3’s conduct of grabbing the AV’s legs, P6 heard that the AV’s pants had fallen down and that SP3 was helping to pull them back up by grabbing the AV’s legs. [Note: P6 was the sole one to mention anything about the AV’s pants. For the facility’s internal investigation, SP3 told P4 and P6 regarding his/her conduct, “[SP1] was struggling with the hold and [the AV] was kicking [his/her] legs, so I grabbed them and kept them secure.”

· Regarding the length of the hold, P6 said that “a release can take some time.” Staff were trained to “process [the youth] out of the hold.” Staff were not supposed to immediately release the hold, but instead to encourage breathing, and then to release one body part at a time.

· Following the incident, SP1-SP3 were retrained on restrictive procedures/physical holds.

· P4, P5, and P6 each did not have, and were not aware of, previous concerns with SP1’s-SP3’s conduct.

For the facility’s internal investigation, SP1 told P4 and P6 that s/he called the AV, “bitch,” during the incident, but denied calling the AV any other names.

In addition, although P4 and P6 each told this investigator that it appeared SP1 had initially been trying to physically escort the AV to the calming room, SP1 did not provide this information to this investigator or during the facility’s internal investigation. However, in SP1’s incident report stated, “When writer approached [the AV] and was getting in position to possibly escort ….”

The facility’s Restrictive Procedures and Handle with Care Manual provided the following information:

· Staff were supposed to use the least restrictive method to deescalate a situation. Initially, staff should listen to the youth, validate the youth’s feelings, focus on one issue at a time, encourage, offer alternative choices, and persuade the youth to agree on a course of action.

· The facility only uses restrictive procedures when necessary and in a manner that takes into consideration the youth's history of trauma to avoid causing the resident additional trauma.

· Physical holding is to be used in emergency situations as a response to imminent danger to the youth or others, and when less restrictive interventions are determined to be ineffective. Physical holding is immobilizing or limiting a person's movement by using body contact as the only source of restraint.

· The emergency use of physical holding must meet the following conditions:

o An immediate intervention is necessary to protect the youth or others from physical harm.

o The physical holding used is the least intrusive intervention that will effectively react to the emergency. Every attempt should be made to assist a resident in gaining appropriate control to avoid the need for physical holding.

o The use of physical holding must end when the threat of harm ends.

o Staff must treat the youth respectfully throughout the procedure.

· The facility trained on various holds, including escort and takedown. Escorts included holding a resident’s arms by one staff person or two. A two-person takedown included one staff person holding a resident’s knees while the second staff person lowered the resident into a sitting position.

· Regarding the “letting go” process:

o “Even though we have regained physical control over the resident, we are still in the middle of an incredibly physically and emotionally charged experience both for ourselves and the resident. In order to assist the resident in regaining his/her internal controls, we must first regain controls over ourselves - including our breathing, tension level and adrenaline rush. Often the resident will respond to a restraint by screaming, swearing, yelling, insulting, accusing and threatening. Our best response to most of these actions is to simply maintain our hold and not respond verbally even though instinctually we want to verbally respond by increasing the volume of our voice. In terms of de-escalating by reducing stimulation, silence in this situation is golden.”

o “The resident's tension begins to de-escalate and you can feel him/her calming down.”

o “The letting go process is a gradual test of how in control the resident is. Just as we moved quickly to gain control, now that we have it we move slowly and gradually in relinquishing control while helping the resident regain it.”

o The staff person then communicates instructions to the resident, including “We are going to let go of one arm and we want you to keep it right where it is.” If the resident complies, then other body parts can be slowly released in the same manner.

Facility documentation stated that the staff persons interviewed and SP2, received training on the facility’s handle with care, including Restrictive Procedures and De-escalation, and on the Reporting of Maltreatment of Minors Act. [Note: Information was also provided that there was not specific training for each specific youth; rather the training was more general. However, the facility required staff to attend staff meetings in which the various youth, including the AV, were discussed.]

Relevant Minnesota Statutes and Rules:

Minnesota Rules part 2960.0050, subpart 1, item R, states, in relevant parts, the license holder must ensure that a resident’s basic rights are protected, including the right to be free from restraint or seclusion used for a purpose other than to protect the resident from imminent danger to self or others, except for the use of disciplinary room time as it is allowed in the correctional facility's discipline plan..

Minnesota Rules part 2960.0710, subpart 6, items A and B, states, in relevant parts, physical holding and seclusion are behavior management techniques which are used in emergency situations as a response to imminent danger to the resident or others and when less restrictive interventions are determined to be ineffective. The emergency use of physical holding or seclusion must meet conditions, including:

A. an immediate intervention is necessary to protect the resident or others from physical harm; and

B. the physical holding or seclusion used is the least intrusive intervention that will effectively react to the emergency;

Conclusion:

A. Maltreatment:

Camera footage showed that on December 5, 2022, the AV threw a flower pot at SP1. SP1 responded by grabbing the AV and eventually ending up on the floor with the AV underneath him/her. SP2 was present, and SP3 arrived later and grabbed the AV’s legs. The AV was not injured.

Although SP1 did not believe his/her conduct was a “hold,” the facility’s policies defined a physical holding as “immobilizing or limiting a person's movement by using body contact as the only source of restraint.” Therefore, SP1’s conduct was a physical hold.

SP1 said that prior to the hold, staff had been providing “a whole weeks of verbal redirection” to the AV. SP1 gave examples of the AV’s maladaptive behaviors from the days prior that were not related to the incident resulting in the physical hold. The AV said that no one gave him/her any directives or instructions, and SP1 and SP3 provided similar information. Although the camera footage did not contain audio, about one second passed between the AV throwing the flower pot and SP1 initiating a physical hold on the AV, which supported the fact that there was no verbal redirection, de-escalation attempt, and/or lesser restrictive method prior to the hold. The conduct of not providing lesser restrictive methods to deescalate the AV prior to initiating a hold was inconsistent with the facility’s policies, which stated, “Every attempt should be made to assist a resident in gaining appropriate control to avoid the need for physical holding,” and violations of Minnesota Rules part 2960.0050, subpart 1, item R and 2960.0710, subpart 6, items A and B.

P3-P6 each stated that throwing an object at a staff person had a potential to warrant a hold. SP1 believed this was an “assault” and that s/he “had a right” to put the AV in a hold. However, the facility’s policies stated that the emergency use of physical holding was only warranted as a response to imminent danger to the resident or others. The camera footage showed that the AV had turned to leave the area after throwing the flower pot, and therefore, there was no longer a threat of imminent danger; the “assault” had ended. Although SP1 believed that the AV might continue to throw other flower pots or hurt others, the AV had not done so; and as a result, the physical hold was initiated out of SP1’s belief of what the AV might do and not what was actually happening. The conduct of implementing a physical hold that was not in response to imminent danger was inconsistent with the facility’s policies and violations of Minnesota Rules part 2960.0050, subpart 1, item R and 2960.0710, subpart 6, items A and B.

Given that the AV was not causing harm to him/herself or others, that SP1’s actions were inconsistent with the facility’s policies and did not include lesser restrictive methods, and that SP1’s conduct likely escalated the AV, there was a preponderance of evidence that there was a failure to provide the AV with necessary care required and a failure to protect the AV from conditions or actions that seriously endangered the AVs physical or mental health when reasonably able to do so.

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

Furthermore, although SP1 denied placing the AV in a “choke hold,” Y2 saw SP1 with the AV in “a head lock” and based on review of the camera footage, this investigator also saw conduct that appeared consistent with this account. In addition, although SP1 denied calling the AV names when speaking to this investigator, the SP acknowledged to calling the AV “bitch” during the facility’s internal investigation. In addition, wrapping an arm around the AV’s neck had a potential to limit the AV’s ability to breathe. Therefore, there was a preponderance of evidence that the AV was subjected to actions that represented a substantial risk of physical injury.

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

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

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

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

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

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

At the time of the incident, SP1-SP3 were working at the facility and therefore, were responsible for the AV’s care and supervision. Facility documentation stated that SP1-SP3 each received training on the facility’s handle with care, including Restrictive Procedures and De-escalation, and on the Reporting of Maltreatment of Minors Act.

Regarding SP2 and SP3:

Although SP2 did not provide information for this investigation, the camera footage showed SP2 reacting to what was happening and not initiating what was happening. Therefore, SP2’s responsibility was mitigated.

Although SP3 grabbed the AV’s legs, which did not appear to be moving, SP3 arrived in the midst of the physical hold, and therefore had limited information about what transpired prior. SP3’s immediate reaction to take control of the AV’s legs was in response to the immediate situation. Therefore, SP3’s responsibility was mitigated.

Regarding SP1:

SP1’s conduct towards the AV, including initiating the hold, wrapping his/her arm around the AV’s head, and knocking the AV to the floor, was inconsistent with the facility’s policies and had a potential to cause injury to the AV. SP1 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 SP1 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.

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. “The physical and non-physical interventions used by staff were not executed in a manner consistent with the program’s restrictive procedure training (Handle with Care) including policies and procedures governing verbal de-escalation strategies. [SP1] admitted to using a profanity when speaking to a resident, which is not consistent with facility policy, mission, values, expectations, or training, specifically regarding resident rights and trauma-informed-care.”

The facility provided additional training to SP1-SP3 regarding “Handle with Care including verbal de-escalation strategies and physical restrictive procedures, as well as trauma-informed care and review of resident rights.”

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

SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal.

On February 15, 2023, the facility was issued a Correction Order for the violations outlined in this report.

Certification:

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

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

doc_type: Maltreatment Finding


state: MN

summary: CORRECTION ORDER

raw_content:
August 19, 2022

Su-Fei Wong, Authorized Agent

Bar None Residential Services

7625 Metro Blbd, Suite 200

Minneapolis, MN 55439

RE:  Report No. 202203218

Bar None Residential Services

License No. 1036846

Dear Ms. Wong:

CORRECTION ORDER

An investigation of Bar None Residential Services was completed regarding report number 202203218 which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegation concerned neglect and physical abuse. The disposition of the investigation report is maltreatment not determined. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

The following violation of state and (or) federal laws and rules was observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

Citation:  Minnesota Rules, part 2960.0710, subpart 6, items C and K.

Violation: The use and documentation of restrictive procedures implemented with a resident (R1) on April 3, 2022, did not meet requirements in the following ways:

a. Documentation of physical holds implemented at 7:04 PM and 7:12 PM did not identify the presence of an immediate threat to the physical safety of the resident or others and did not explain why the procedure needed to be used;

b. Documentation of the physical hold implemented at 7:12 PM indicated the physical hold ended when R1 was safely in the calming room, however, the physical hold continued for eight minutes after arriving to the calming room.  Documentation stated that the type of hold was transitioned at 7:14 PM for R1’s comfort, that R1 continually asked to be released without engaging in a de-escalation process, but did not contain any information indicating R1’s behavior posed a risk of imminent danger that required the physical hold to continue; and

c. The use of physical holding was not documented immediately after the incident concluded; the “Restrictive Procedures Report” was completed on April 5, 2022.

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

If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Heather Prior, at 651-431-6500.

Sincerely,

Beth Virden, Senior Investigator

Office of Inspector General

Licensing Division

651-431-6572

Enclosure

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


report_date: August 9, 2022

raw_content:
August 9, 2022

Su-Fei Wong, Authorized Agent

Volunteers of America Minnesota and Wisconsin

7625 Metro Blvd

Minneapolis, MN 55439-3053

License Number: 1036848

CORRECTION ORDER

Dear Su-Fei Wong:

On July 28, 29 and August 1, 2022, a modified licensing review of Volunteers of America, Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN 55303, 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 2960.0220, chemical dependency certification under Minnesota Rules, parts 2960.0430 through 2960.0490, shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530, mental health certification under Minnesota Rules, parts 2960.0580 through 2960.0690 and restrictive procedures certification under Minnesota Rules, part 2960.0710 As a result of this modified licensing review a Correction Order is being issued.

A. Reason for Correction Order

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

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

Practices

1. Citation: Minnesota Rules, part 2960.0710, subpart 11, item A.

Violation: The restrictive procedures quarterly review ending March 31, 2022 did not include patterns or problems indicated by the following:

a. Duration and day of the week (Omegon unit); and

b. Time of day, day of the week and individuals involved (Bar None Shelter Plus East).

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

2. Citation: Minnesota Rules, parts 2960.0450, subpart 2, item B and 2960.0460, subpart 5, item C.

Violation: The license holder failed to ensure chemical dependency treatment services were provided by a qualified individual. The staff person providing group therapy, chemical health awareness, sexuality and health problems related to chemical use (personnel file numbered 6) was not a licensed alcohol and drug counselor and did not meet the requirements to provide treatment services to adolescents.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all chemical dependency treatment services are provided by a qualified alcohol and drug counselor and meet all applicable requirements.

3. Citation: Minnesota Statutes, section 245A.081, paragraph (a), clause 2.

Violation: The license holder failed to ensure a term of the Settlement Agreement dated November 29, 2021 was followed when maintenance personnel did not conduct a bi-weekly audit of cleaning supplies as required in the Hazardous Materials, Chemicals, and Sharps Safety Plan from January 2022 to the time of the licensing review.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must monitor the implementation of the Hazardous Materials, Chemicals, and Sharps Safety Plan and meet all applicable requirements. Within 30 days of receipt of this order, submit a plan that includes how compliance with this term will be monitored and the bi-weekly safety check documentation completed from August 1-August 31, 2022.

Personnel Files

4. Citation: Minnesota Rules, part 2960.0100, subpart 5.

Violation: Two of five personnel files reviewed for requirements governing the documentation of training (personnel files numbered 4 and 5) did not meet requirements. The annual training plan did not include the name of the entity that provided the training.

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

Resident Files

Resident files reviewed are identified in the following manner:

· Omegon mental health and chemical dependency treatment unit: Resident files numbered 1, 2, 4, 5 and 7

· Bar None Shelter Plus unit: Resident files numbered 3 and 6

5. Citation: Minnesota Rules, part 2960.0520, subpart 3, item B.

Violation: One of two resident files reviewed for requirements governing the immediate needs plan (resident file numbered 3) did not meet requirements. The plan did not specify short-term objectives and methods for meeting each need identified in Minnesota Rules, part 2960.0520, subpart 3, item A.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the immediate needs plan meets all applicable requirements. Within 30 days of receipt of this order, submit an immediate needs plan for one resident to demonstrate compliance.

6. Citation: Minnesota Rules, part 2960.0070, subpart 4.

Violation: One of three resident files reviewed for requirements governing the inventory and handling of resident property (resident file numbered 2) did not meet requirements. The file did not contain documentation to demonstrate that the resident’s belongings were inventoried upon admission.

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

7. Citation: Minnesota Rules, part 2960.0485.

Violation: One of two resident files reviewed for requirements governing the initial services plan (resident file numbered 4) did not meet requirements. The initial services plan was not completed during or immediately following the intake interview.

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

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

Violation: One resident file was reviewed for requirements governing educational services (resident file numbered 3) and did not meet requirements. The file did not contain documentation to demonstrate the license holder provided education about chemical health to a resident who has had a problem with inappropriate chemical use, but does not have sufficient history to refer to treatment.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure educational services are provided and meet all applicable requirements.

9. Citation: Minnesota Rules, parts 2960.0490, subparts 2, 3, items C, D and E and 2960.0600, item A, 2960.0620, subpart 1, item B.

Violation: Four of four resident files reviewed for requirements governing the individual treatment plan did not meet requirements in the following ways:

a. The treatment plan did not include the following:

1. Specific objectives to be used to address the treatment goals in which a problem has been identified (resident file numbered 5);

2. The frequency for each intervention listed (resident files numbered 2 and 5);

3. Specific interval at which resident progress should be reviewed (resident file numbered 2);

4. Minimum outcomes that are to be met before the resident is discharged (resident files numbered 2, 4 and 5);

5. Individuals responsible for providing treatment (resident files numbered 1,2, 4 and 5);

6. The symptoms and behaviors that the psychotropic medication is to alleviate (resident files numbered 1, 2 and 5).

b. The treatment plan was not signed by the resident and the licensed alcohol and drug counselor (resident files numbered 2 and 4); and

c. The treatment plan was not signed by the resident for plans completed after December 30, 2021 (resident file numbered 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements. Within 30 days of receipt of this order, submit individual treatment plans for two residents to demonstrate compliance has been achieved.

10. Citation: Minnesota Rules, part 2960.0490, subpart 5.

Violation: Three of three resident files reviewed for requirements governing the treatment plan review did not meet requirements in the following ways:

a. The individual treatment plan was not reviewed no less frequently than every two weeks for the following:

1. July 1, 2022 through July 23, 2022 (resident file numbered 2);

2. July 8, 2022 through July 29, 2022 (resident file numbered 4); and

3. July 7, 2022 through July 27, 2022 (resident file numbered 5).

b. Services did not change when expected outcomes were not being achieved by the resident as demonstrated by the resident’s increase in chemical use (resident file numbered 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the treatment plan is reviewed by an alcohol and drug counselor and meets all applicable requirements.

11. Citation: Minnesota Rules, part 2960.0450, subpart 2, item C.

Violation: Two of three resident files reviewed for requirements governing required chemical dependency treatment services (resident files numbered 2 and 5) did not meet requirements. The file did not contain documentation to demonstrate that the license holder provided education concerning tobacco addiction and cessation resources.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that chemical dependency treatment services are provided and meet all requirements.

12. Citation: Minnesota Rules, part 2960.0490, subpart 4.

Violation: Three of three resident files reviewed for requirements governing progress notes (resident files numbered 2, 4 and 5) did not meet requirements. Progress notes did not include whether the services have had the desired impact.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that progress notes meet all applicable requirements. Within 30 days of receipt of this order, submit two weekly progress reviews and two group notes for two residents to demonstrate compliance has been achieved.

13. Citation: Minnesota Rules, part 2960.0620, subparts 5, item A, 7, items A and C.

Violation: Two of two resident files reviewed for requirements governing the psychotropic medication review and the informed consent (resident files numbered 1 and 2) did not meet requirements in the following ways:

a. The psychotropic medication reviews completed after admission did not include the data collected since the last review; and

b. Admission informed consent information did not include:

1. Diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed; and

2. The course of the condition with and without the pharmacological and nonpharmacological treatment options.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the psychotropic medication review and the informed consent meets all requirements. Within 30 days of receipt of this order, submit informed consents for two residents to demonstrate compliance has been achieved.

14. Citation: Minnesota Rules, part 2960.0710, subparts 6, item K, 10.

Violation: One resident file was reviewed for requirements governing restrictive procedures and the administrative review (resident file numbered 1) and did not meet requirements in the following ways:

a. Restrictive procedure documentation did not include why less restrictive measures failed or were found to be inappropriate for procedures on January 19 and March 20, 2022; and

b. The administrative review was not conducted by someone other than the person who decided to impose the restrictive procedure or that person’s immediate supervisor for a procedure on March 20, 2022.

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

15. Citation: Minnesota Rules, part 2960.0190, subparts 1, item A and 2.

Violation: Three of three resident files reviewed for requirements governing discharge documentation did not meet requirements. The plan did not include:

a. How the resident may deal with issues and potential challenges within the environment they will return to (resident files numbered 3 and 6);

b. Which services included education, were provided directly or indirectly to the resident and who provided the services (resident files numbered 3, 6 and 7); and

c. Which services, including education, that were recommended in the resident’s case plan or treatment plan but were not provided to the resident (resident files numbered 3, 6 and 7).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that discharge documentation meets all applicable requirements. Within 30 days of receipt of this order, submit a transition services plan from each unit to demonstrate compliance.

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

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

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

2. By mail to:

Commissioner, Department of Human Services

ATTN: Madelyn Gilbertson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Recommendation

The following recommendation is not a requirement of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas.

· DHS recommends the license holder develops a process to eliminate the use of multiple treatment plans and have one unified treatment plan for chemical dependency and mental health treatment services.

Failure to follow this recommendation will not result in a fine or action against your license at this time. However, should failure to follow this recommendation result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license.

C. 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 Madelyn Gilbertson as soon as possible at 651-448-3583.

Heather Prior, MH/SUD/CRF Licensor

Licensing Division

Office of Inspector General

651-431-2694

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


facility_name: Nexus East Bethel Family Healing

raw_content:
July 26th, 2024

Michelle Murray, Authorized Agent

Nexus East Bethel Family Healing

900 189th Avenue Northeast

East Bethel, MN 55011

License Number: 1119782 (PRTF)

CORRECTION ORDER

Dear Michelle Murray:

On May 13th, 14th, and 15th 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Nexus East Bethel Family Healing located at 900 189th Avenue NE East Bethel, MN 55011. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Psychiatric Residential Treatment Facilities (PRTF) under the PRTF Variance to Minnesota Rules, chapter 2960. As a result, DHS is issuing this order which requires you to take the corrective 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.

PRACTICES

1. Violation: The license holder did not ensure that all treatment team members participated in clinical supervision or an ancillary meeting for each calendar week they worked in three of three weeks reviewed. Additionally, the ancillary meetings held during these weeks were not conducted by a clinical supervisor or a mental health practitioner who participated in the weekly meeting:

a. February 18, 2024;

b. April 21, 2024; and

c. May 5, 2024.

Rule Violated: Minnesota Variance, section R2960V.13.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision and ancillary meetings meet all applicable requirements.

2. Violation: The license holder’s review of their quality assurance plan did not meet requirements. The following required components have not been reviewed:

a. Resident outcomes, including an evaluation of the outcome data to identify ways to improve the effectiveness of the services provided to residents and improve resident outcomes;

b. Attaining and evaluating feedback from residents, family members, staff, and referring agencies concerning the services provided;

c. Restraint and seclusion data;

d. 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;

iv. Modifying policies, procedures, training plans, or residents’ individual treatment plans in response to the findings of the review; and

e. Self-monitoring of compliance, including the license holder’s actions to improve the program’s compliance with the requirements of this variance.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure to conduct a quarterly review of the quality assurance and improvement plan that meets all applicable requirements.

3. Violation: The quarterly review of the patterns of the use of restraint and seclusion did not include the following required components:

a. Any patterns or problems indicated by similarities in the duration of the use of a procedure;

b. Any injuries that occurred as a result of the use of restraint and seclusion;

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

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

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

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

PERSONNEL FILES

4. Violation: SP8 began a position allowing direct contact with persons served by the program on January 15, 2024, and has since had a legal name change. The license holder did not initiate a new background study or notify the commissioner of the name change for SP8.

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

Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Since the licensing review, the license holder has corrected this violation and no further action is required.

5. Violation: Eight of eight personnel files reviewed for requirements governing orientation trainings did not meet requirements in the following ways:

a. There was no documentation to demonstrate the staff person received orientation on the following required topics prior to providing direct contact services:

i. The requirements in Minnesota Statutes, section 245A.65, subdivision 3 (personnel files numbered 4 and 5);

ii. Minnesota Statutes, section 626.556, subdivisions 2, 3, and 7 (personnel files numbered 4 and 5);

iii. Resident rights (personnel files numbered 1 and 4);

iv. Emergency procedures (personnel files numbered 2 and 5);

v. Resilience and recovery concepts and principles (personnel file numbered 4);

vi. Gender based needs (personnel file numbered 4);

vii. Resident confidentiality (personnel file numbered 5); and

viii. Training related to specific activities and job functions that the staff person will be responsible to carry out (personnel file numbered 4).

b. There was no documentation to demonstrate the staff person received the following required trainings within 30 days of providing direct contact services:

i. Facility policies and procedures (personnel files numbered 1 through 4);

ii. The treatment needs of residents, including psychiatric and co-occurring disorders (personnel files numbered 1 through 5 and 7 through 8);

iii. Best practice service delivery (personnel file numbered 4).

c. There was no documentation of the credentials of the people who certified the completion of training (personnel files numbered 1 through 8).

Rule Violated: Minnesota Variance, R2960V.16, subparts 2 and 6.

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

RESIDENT FILES

6. Violation: One of three resident files reviewed for requirements governing resident rights did not meet requirements (resident file numbered 3). There was no documentation to demonstrate the license holder provided the resident’s guardian with a written copy of the resident’s basic rights information within five days of admission.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must provide the resident’s parent, legal guardian, or custodian with a written copy of the resident’s basic rights information within five days of admission.

7. Violation: Three of three resident files reviewed for requirements governing individual plans of care did not meet the following requirements:

a. The resident’s preliminary plan of care did not include:

i. As assessment of needs related to the resident’s health and safety (resident files numbered 1 and 3);

ii. At least one treatment goal (resident files numbered 1 through 3); and

iii. The resident’s treatment schedule (resident files numbered 1 and 3).

b. The resident’s individual plan of care did not include:

i. Measurable treatment objectives (resident files numbered 1 through 3);

ii. The frequency of the interventions identified (resident file numbered 1);

iii. Medication management goals (resident files numbered 1 through 3); and

iv. Education about chemical health provided to residents who display issues related to inappropriate chemical use but who do not have a sufficient chemical use history to refer to treatment (resident files numbered 1 and 3);

c. The individual plan of care was implemented later than ten days after admission (resident files numbered 1 and 3);

d. The multidisciplinary treatment team did not meet to review the resident’s individual plan of care at least once during the first 10 days following admission (resident files numbered 1 and 3) and every 30 days thereafter (resident file numbered 1); and

e. The individual plan of care was not signed by the multidisciplinary team member, the medical director, who approved the plan of care (resident file numbered 1).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must follow all requirements governing a resident’s individual plan of care. Within 30 days receipt of this order, submit an individual plan of care that meets all requirements.

8. Violation: One of three resident files reviewed for requirements governing the health screening did not meet requirements (resident file numbered 2). Documentation did not demonstrate that a health screening was completed within 72 hours of admission.

Rule Violated: Minnesota Variance, R2960V.08, subpart 2, item A.

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

9. Violation: One of three resident files reviewed for requirements governing health care services did not meet requirements (resident filed numbered 1). Documentation did not demonstrate that the license holder maintained accurate and thorough documentation of medical and health records of residents, including significant medical or health related information.

Rule Violated: Minnesota Variance, R2960V.08, subpart 2, item G.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must meet all requirements related to healthcare services.

10. Violation: Three of three resident files reviewed for requirements governing medication reconciliation did not meet requirements (resident files numbered 1 through 3). There was no documentation to demonstrate medication reconciliation was conducted.

Rule Violated: Minnesota Variance, R2960V.08, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication reconciliation meets all applicable requirements. Within 30 days receipt of this order, submit documentation of the medication reconciliation process that demonstrates compliances.

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

a. The license holder did not obtain written or verbal authorization from the resident’s legal guardian prior to administering medications (resident file numbered 3);

b. Documentation did not identify occurrences of a medication not being administered as prescribed (resident files numbered 1 and 3); and

c. Standing medication orders were not individualized to the resident; they were not signed by the prescribing practitioner (resident files numbered 1 through 3).

Rule Violated: Minnesota Variance, R2960V.08, subpart 4, items A, B and E.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must meet all requirements governing medication administration.

12. Violation: Three of three resident files reviewed for requirements governing the use of psychotropic medications did not meet requirements in the following ways:

a. The prescribing practitioner did not document the following required components (resident files numbered 1 through 3):

i. A description in observable and measurable terms of the symptoms and behaviors that 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;

b. There was no documentation to demonstrate a prescribing practitioner conducted a psychotropic medication review at least weekly for the first month after admission (resident file numbered 1).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication reviews meet all applicable requirements. Within 30 days receipt of this order, submit documentation of a psychotropic medication review to demonstrate compliance.

13. Violation: Two of two resident files reviewed for requirements governing informed consent for psychotropic medications did not meet requirements in the following ways:

a. Informed consent for an antipsychotic medication was not obtained in writing (resident files numbered 1 and 3);

b. Informed consent was not obtained by the license holder within 30 days to continue the use of psychotropic medication, after verbal consent expired (resident file numbered 1); and

c. There is no documentation that the following information was not provided orally or in writing to the resident and their legal guardian:

i. The pharmacological treatment options available (resident files 1 and 3);

ii. The commonly known brand name of the psychotropic medication to be used (resident file numbered 1);

iii. An explanation that consent may be refused or withdrawn at any time and that the consent expires yearly for written consent (resident file numbered 3);

iv. The names, addresses, and phone numbers of appropriate professionals to contact if questions or concerns arise (resident files numbered 1 and 3); and

v. The signature of the resident and resident’s legal representative acknowledging they have been talked to about the medication and that they agree to the medication and dosage (resident files numbered 1 and 3).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must adhere to all requirements governing obtaining informed consent.

14. Violation: Two of three resident files reviewed for requirements governing monitoring for medication side effects did not meet requirements (resident files numbered 1 and 3). Documentation did not demonstrate that the frequency of side effect monitoring was determined.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must document and monitor for side effects as determined by the nurse.

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

a. The license holder did not conduct a debriefing within 24 hours of the use of restraint on April 4, 2024, and May 10, 2024 (resident file numbered 1); and

b. The license holder did not complete an administrative review within three working days after the physical hold, and did not provide the resident with the opportunity to have a legal representative or advocate participate in the debriefing for the following incidents:

i. January 29, 2024 (resident file numbered 2);

ii. January 21, 2024 (resident file numbered 2);

iii. April 19, 2024 (resident file numbered 2);

iv. April 4, 2024 (resident file numbered 1);

v. April 23, 2024 (resident file numbered 1); and

vi. May 10, 2024 (resident file numbered 1).

Rule Violated: Minnesota Variance, R2960V.11, subparts 3 and 4.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must conduct debriefings after all uses of restrictive procedures that follow all timelines and components of the requirement.

16. Violation: One resident file reviewed for requirements governing discharge planning did not meet requirements. There was no documentation to demonstrate the license holder prepared an aftercare plan that addressed the clinical rationale for medications (resident file numbered 2).

Rule Violated: Minnesota Variance, R2960V.07, subpart 3, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must develop aftercare plans that meet all 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 651-431-6270 or at Hannah.Horsch@state.mn.us.

Sincerely,

Hannah Horsch, 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/