raw_content:
April 15, 2025

Katie Perzel, Authorized Agent

Bar None Residential Services

7625 Metro Blvd Ste 200

Minneapolis, MN 55439

License Number: 1036848 (CRF)

Report Numbers: 202409503, 202405253, 202407979, 202408399, 202411025 and 202500960

CORRECTION ORDER

Dear Katie Perzel:

On February 10, 2025 through 13, 2025, the Department of Human Services (DHS) conducted a licensing review and investigation at your facility located at 22426 Saint Francis Blvd, Anoka, Minnesota, 55303. As a result of this visit, DHS determined that you are in violation of 24 of the children’s residential facilities rules and statutes. 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.

PRACTICES

1. Violation: The license holder did not have a copy of the resident’s rights, program abuse prevention plan and the internal and external reporting policies and procedures posted on either living unit.

Rule/Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), and Minnesota Rules, part 2960.0050, subpart 3, items C and D.

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

2. Violation: The physical environment did not provide for the comfort, privacy and dignity of the residents. The physical plant was missing a bedroom door (Omegon unit) and curtains (Haven unit).

Statute Violated: Minnesota Rule, part 2960.0110, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the physical environment provides privacy to the residents. Within 30 days receipt of this order, submit documentation that demonstrates compliance.

3. Violation: 2 of 13 Internal reviews (IR) of alleged maltreatment did not meet requirements. The internal reviews did not indicate the following:

a. Related policies and procedures were followed (IR dated November 21, 2024); and

b. The policies and procedures were adequate (IR dated April 23, 2024).

Rule Violated: Minnesota Rule, section 245A.66.

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

4. Violation: The annual evaluation of program strengths and weaknesses for calendar year 2024 did not include the number of residents served in the past 12 months, and the number of residents likely to be served in the next 12 months.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 6.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the annual evaluation of program strengths and weaknesses meet all applicable requirements.

5. Violation: The quarterly review of patterns of restrictive procedures dated April 15, 2023, July 1, 2023, and July 1, 2024, did not meet requirements. The review did not consider any patterns or problems indicated by similarities in:

a. The day of the week; and

b. The duration of the use of a procedure.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 11, item A.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022.

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

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

a. December 22 through December 24, 2024; and

b. February 2 through February 8, 2025.

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

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

7. Violation: 3 of 23 grievances reviewed did not meet requirements. There was no documentation to demonstrate the license holder provided a written response within five days of the resident filing a grievance on the following dates:

a. June 6, 2024;

b. September 13, 2024; and

c. December 3, 2024

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

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

8. Violation: The license holder did not ensure that hazardous chemicals were adequately stored to ensure the residents right to live in safe surroundings was protected. During the physical plant tour, it was observed by a DHS licensor that a cleaning closet was left open, allowing access to chemicals.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 1, item H.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure youth do not have access to cleaning chemicals. Within 30 days receipt of this order, submit documentation demonstrating that staff have been retrained on job duties related to the safe storage of cleaning supplies.

9. Violation: The license holder did not provide the commissioner with timely access to resident files 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 meets all applicable requirements.

PERSONNEL FILES

10. Violation: One of eight personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 4). There was no documentation of the specific medication assistance training in the staff persons file.

Rule Violated: Minnesota Rules, part 2960.0080, subparts 11, item D.

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

11. Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways:

a. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 3 through 5 and 8);

b. Training to the following required topics was completed late:

i. Vulnerable adults maltreatment reporting requirements and definitions for calendar year (CY) 2024 (personnel file numbered 8);

ii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was not completed in CY 2024 or 2025 (personnel file numbered 8);

iii. The maltreatment of minors reporting requirements and definitions was completed late in CY 2024 (personnel file numbered 8); and

iv. HIV Minimum Standards Training was completed late for the CY 2024 (personnel file numbered 8).

c. Training on the license holders program abuse prevention plan was not completed in CY 2024 or 2025 (personnel file numbered 8);

Rule/Statute Violated: Minnesota Statutes, sections 245A. 19, paragraph (a), and 245A.65, subdivision 3; and Minnesota Rules, parts 2960.0080, subpart 14 and 2960.0100, subpart 3, item A.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance for personnel files numbered 3 through 5 and 8.

12. Violation: Three of six personnel files reviewed for requirements governing individual staff development plans did not meet requirements (personnel files numbered 6 through 8). There was no documentation that the annual individual staff development plan was developed within 90 days after the person began employment.

Rule Violated: Minnesota Rules, part 2960.0660, subpart 1, item A.

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

RESIDENT FILES

13. Violation: Four of four resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 4, 5 and 7). The file did not contain documentation that the license holder completed an inventory of the resident’s personal property, including clothing, upon admission.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022.

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

14. Violation: One of two resident files reviewed for requirements governing HIV training in substance use disorder treatment programs did not meet requirements (resident file numbered 2). Orientation to the HIV minimum standards was not completed within 72 hours of admission.

Statute Violated: Minnesota Statute, section 245A.19 (b).

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

15. Violation: One resident file reviewed for requirements governing vulnerable adult orientation and the individual abuse prevention plan (resident file numbered 2) did not meet requirements in the following ways:

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

b. The individual abuse prevention plan did not assess the persons susceptibility to abuse by other vulnerable adults.

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

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

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

a. The health screening did not address the residents history of abuse (resident file numbered 4);

b. The mental health screening, the screening for sexually abusive behavior, and vulnerability assessment were completed late (resident file numbered 4); and

c. There was no documentation that a health screening was completed (resident file numbered 7).

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

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

17. Violation: Four of four resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways:

a. The individual treatment plan was not completed within 10 working days of admission (resident files numbered 1 and 2);

b. The license holder did not document a description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident file numbered 7);

c. There was no documentation in the youth’s file describing how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youth’s siblings (resident files numbered 1 and 7); and

d. The program did not identify the treatment goals the resident must meet to have access to increased freedom of movement or be placed in a less restrictive appropriate treatment setting (resident file numbered 3).

Rule/Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4 (h) and Minnesota Rules, parts 2960.0490, subpart 2, 2960.0620, subpart 1, item B, 2960.600 and 2960.0700, subpart 1, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022 and November 12, 2024.

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

18. Violation: One of two resident files reviewed for requirements governing service plan reviews did not meet requirements (resident file numbered 1). The plan review was not recorded in the six dimensions.

Rule Violated: Minnesota Rules, part 2960.0490, subpart 5.

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

19. Violation: Three of three resident files reviewed for requirements governing health care services did not meet requirements. There was no documentation of the following:

a. The license holder contacted a newly admitted resident’s prescribing medically licensed person to verify information regarding prescribed medication, including the symptoms that would warrant consultation with a physician (resident file numbered 4);

b. The quantity of prescription drugs initially received from the pharmacy (resident files numbered 4 and 7);

c. A resident’s refusal to take prescription medication (resident file numbered 7); and

d. Prescription medicine belonging to a resident must be given to the resident's parent or legal guardian upon the resident's release or must be disposed of according to a pharmacy-approved plan. The license holder must note the disposition of the resident's medicine in the resident's file (resident files numbered 1 and 4).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D, E and F.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care services meet all applicable requirements.

20. Violation: Two of three resident files reviewed for requirements governing psychotropic medication did not meet requirements (resident files numbered 2 and 7). The license holder, under the direction of a medically licensed person, must document and check for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication or a significantly increased or decreased dose of a currently used psychotropic medication, and at least quarterly thereafter. There was no documentation on medication monitoring for the following weeks:

a. March 16 through 22, 2024 (resident file numbered 2);

b. October 13 through 19, 2024 (resident file numbered 7);

c. October 20 through 26, 2025 (resident file numbered 7);

d. January 5 through 11, 2025 (resident file numbered 7); and

e. January 26 through February 1, 2025 (resident file numbered 7).

Rule Violated: Minnesota Rules, part 2960.0620, subpart 2

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

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

a. The information communicated in obtaining consent did not include:

i. The diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed (resident file numbered 2);

ii. The expected benefits of the medication, including the level to which the medication is to change the symptoms and behavior (resident files numbered 2 and 7);

iii. The pharmacological treatment option available and the course of the condition with and without the treatment options (resident files numbered 2 and 7);

b. There was no documentation that demonstrated that the resident was informed or involved in the decision making process.

Rule Violated: Minnesota Rules, part 2960.0620, subparts 6 and 7, items A, B and C.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022 and June 8, 2023.

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

22. Violation: Four of four resident files reviewed for requirements governing restrictive procedures did not meet requirements in the following ways:

a. The license holder did not document the time of day that a physical escort took place on September 5, 2024 (resident file numbered 1);

b. The license holder utilized a room that was not approved for seclusion on September 5, 2024 (resident file numbered 1);

c. The staff person who implemented the emergency use of physical holding or seclusion did not document its use immediately after the procedure on December 30, 2024 (resident files numbered 4 and 5) and January 4 and 14, 2025 (resident file numbered 7);

d. Documentation did not specify why less restrictive measures failed or were found to be inappropriate on September 5, 2024 (resident file numbered 1) and December 30, 2024 (resident file numbered 5);

e. There was no documentation of the time the physical hold or seclusion began and the time the resident was released on September 5, 2024 (resident file numbered 1) and December 30, 2024 (resident file numbered 5);

f. The license holder used a prone restraint on a resident on August 3, 2024 (resident file numbered 7); and

g. The administrative review of the use of restrictive procedures was not completed within three working days on reviews dated December 30, 2024 (resident files numbered 4 and 5) and January 4 and 14, 2025 (resident file numbered 7).

Rule/Statute Violated: Minnesota Statutes, section 245A.11, subdivision 3 and Minnesota Rules, part 2960.0710, subparts 5, 6 items L, M, and K and 10.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated August 9, 2022.

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

23. Violation: Four of four resident files reviewed for requirements governing discharge procedures did not meet requirements in the following ways:

a. The files did not contain documentation to demonstrate the license holder returned the residents property to the resident upon discharge (resident files numbered 1 and 3 through 5); and

b. There was no documentation that demonstrated that the license holder conferred with other interested persons to review issues involved with the decision to discharge a resident, prior to discharge (resident files numbered 4 and 5).

Rule Violated: Minnesota Rules, part 2960.0090, subparts 2 and 3.

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

24. Violation: Two of three resident files reviewed for requirements governing aftercare did not meet requirements (resident files numbered 4 and 5). There was no documentation that the license holder provided monthly aftercare services to the resident after discharge, for a period of six months.

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

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

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

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

1. By secure email to: maddy.moore@state.mn.us; or

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

ATTN: Maddy Moore

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Questions

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

Sincerely,

Maddy Moore, 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: Bar None Residential Services

report_date: November 27, 2024

summary: CORRECTION ORDER

raw_content:
November 27, 2024

Su-Fei Wong

22426 Saint Francis Blvd

Anoka, MN 55303

RE:  Report No. 202405159

Bar None Residential Services

License No. 1036848

Dear Su-Fei Wong:

CORRECTION ORDER

An investigation of Bar None Residential Services was completed regarding report number 202405159 which alleged violation of Minnesota Statutes, section 626.557, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegations concerned neglect. The disposition of the investigation report was maltreatment not determined and maltreatment determined. One violation was noted.

VIOLATION AND CORRECTION ORDER

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 violation 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 statutes section 260E.06, subdivision 1, paragraph (a).

Violation: A person who knows or has reason to believe that a child is being or has been maltreated failed to immediately report the information to the local welfare agency, agency responsible for investigating the report, police department, county sheriff, tribal social services agency, or tribal police department.

On January 11, 2024, a staff person (Person one) allegedly permitted a child to use a vaping device. Supervisory/administrative staff persons, including Persons two, three, and four, were each made aware of the alleged incident, but a report of alleged maltreatment was not made.

Corrective Action Ordered: Immediately and on an ongoing basis, you must maintain compliance for reports of alleged maltreatment as required in this statute.

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, Madelyn Gilbertson, at 651-431-4585.

Sincerely,

Carla Harvieux, Investigator

Office of Inspector General

Licensing Division

carla.harvieux@state.mn.us

651-431-6616

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


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: 202405159

Date Issued: November 27, 2024

Name and Address of Facility Investigated:

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

Disposition:

Allegation One: Maltreatment not determined.

Allegation Two: Maltreatment determined.

Allegation Three: Maltreatment not determined.

License Number and Program Type:

1036848-CRF (Children’s Residential Facility)

Investigator(s):

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

651-431-6616

Suspected Maltreatment Reported:

Allegation One: It was reported that on January 19, 2024, an alleged victim (AV1) left his/her bedroom and entered an alleged victim’s (AV2’s) bedroom. The AVs spent two hours in the bedroom and had consensual sexual intercourse. Two staff persons (SP1 and P1) were on shift when the incident occurred.

Allegation Two: It was reported that on February 6, 2024, SP1 saw the AVs kiss, permitted the AVs to be unsupervised in a facility storeroom, and saw AV2 use a vaping device or smoke a “joint,” but took no action.

Allegation Three: It was reported that another staff person (SP2) permitted AV1 to use SP2’s personal vaping device and brought vaping devices to the facility for AV1 to use.

Date of Incident(s): Prior to July 24, 2024

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

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

The incident in Allegation One was initially reported to the Department of Human Services (DHS) in January of 2024, but was not assigned for investigation at that time. However, in late July of 2024, DHS received information that on February 6, 2024, there was another incident (Allegation Two) regarding supervision concerns with SP1 and the AVs. Both the January and February incidents were assigned for further investigation in July of 2024. During the investigation of Allegations One and Two, this investigator obtained the information in Allegation Three, and it was added to this report.

Pertinent information was obtained during a site visit conducted on August 6, 2024; from documentation at the facility; and through interviews conducted with current and former facility staff persons (P1, P2, P3, and SP2). AV1 and AV2 were no longer at the facility, but AV1 and two of his/her family members (FM1 and FM2) provided information to this investigator regarding the facility which was included below. AV2 agreed to talk with this investigator by telephone, but when the investigator called AV2 at the scheduled time, no one answered the phone. AV2 did not respond to additional attempts to contact him/her. Two letters, one certified, were sent to SP1 requesting an interview with this investigator, and s/he responded to the letters and other attempts to contact him/her, but s/he did not schedule an interview. However, SP1 provided information in the facility’s Internal Review, which was included below.

The facility provided services to youth based on their needs that included mental health therapies and case management. The doors of the AVs’ bedrooms opened into a common area of the facility with couches where youths and staff persons might spend time together. There was a video recording system at the facility that recorded some common areas of the facility, and the videos were routinely reviewed by supervisory staff persons to ensure that the facility’s policies and procedures were followed. The recordings from January and February of 2024 were reviewed by supervisory staff persons shortly after they became aware of the incidents, but in July of 2024, the recordings were no longer retained by the facility.

Facility documentation showed that AV1 had a history of substance use and of using vaping devices, but it was unknown how s/he obtained the devices. AV1 stated s/he had nicotine withdrawal symptoms (for which s/he received medication) and wanted to use a vaping device. AV1 had poor impulse control and might be vulnerable to sexual exploitation, but the Vulnerability and Sexual Abuse Behavior Screen completed for AV1 when s/he was admitted to the facility showed that AV1 had no history of sexual abuse and no history of sexually inappropriate behavior. No information showed whether AV1 had a history of providing inaccurate information. At the time of the incidents, AV1 was 14 years old. AV1 was social and liked to spend time with his/her friends.

AV2 was diagnosed with a physical disability and wanted to “fit in” with peers but had a history of making unsafe or impulsive decisions, which placed him/her at risk. AV2’s Placement Request showed that s/he had no prior history of sexual abuse or sexually inappropriate behavior but was sexually active. No information showed whether AV2 had a history of providing inaccurate information. At the time of the incidents, AV2 was 16 years old. AV2 loved his/her family members and was very loyal.

The AVs did not require additional or one-to-one supervision at the time of the incidents, and after the incidents occurred the facility updated their plans to alert staff persons of the incidents.

The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Minors Act prior to the incident. SP1’s Orientation Checklist was filled out and signed by the staff persons who trained SP1, but SP1 had not signed the Checklist. Documentation showed that SP1 completed a total of 80 training hours including five eight-hour office training days and four ten-hour “shadow shifts,” which were all completed before SP1 worked his/her first “official shift.” On

January 25, 2024, SP1 was given a Coaching to Achieve Form for the January 19, 2024, incident. SP1’s employment at the facility ended on February 12, 2024, because of the February 6, 2024, incident.

Allegation One: It was reported that on January 19, 2024, AV1 left his/her bedroom and entered AV2’s bedroom. The AVs spent two hours in the bedroom and had consensual sexual intercourse. SP1 and P1 were on shift when the incident occurred.

Facility documentation, the facility’s Internal Review, and interviews with this investigator provided the following:

· AV1 said that on the date of the incident, s/he left his/her bedroom and entered AV2’s bedroom while SP1 was on shift. The AVs had sexual intercourse in the bedroom and was unsure whether SP1 was aware that s/he was in AV2’s bedroom. The AVs were not unsupervised in their respective bedrooms on any other occasion, according to AV1.

· Information was consistent that P2 and P3, who were supervisory staff persons, reviewed recordings from the facility’s video recording system and observed that at 1:11 a.m., on January 19, 2024, AV1 left his/her bedroom and entered AV2’s bedroom, where s/he stayed for approximately one and a half hours. P1 and SP1 were on shift at the time, but P1 was in the facility office possibly counting medication when AV1 left his/her bedroom and was not responsible for supervising the AVs, according to P2. P2 talked individually with the AVs, and they each said that they had consensual sexual intercourse in AV2’s bedroom. The facility completed an Incident Report, began investigating the incident, moved the AVs’ bedrooms, and rearranged the furniture in the common areas to improve staff persons’ line of sight into the common areas.

· In the facility’s Internal Review, AV1 said that s/he was in AV2’s bedroom for about an hour and thought that SP1 and P1 were unaware that s/he was in the bedroom. AV1 denied that s/he and AV2 had sexual contact and said that s/he and AV2 talked and hung out. AV2 said that AV1 was in his/her bedroom for about 15-20 minutes but s/he thought that SP1 and P1 saw AV1 in his/her bedroom but did not say anything. AV2 said that s/he and AV1 talked in the bedroom and provided no additional information.

· P2 stated that on the video recordings, s/he saw AV1 leave his/her bedroom, crawl to the couches, hide behind them, then make his/her way to AV2’s bedroom in less than a minute. SP1 had just completed a room check on AV1 and other youths when AV1 exited his/her bedroom and SP1 was sitting in the common area with his/her back toward the AVs’ bedroom doors when AV1 went from his/her bedroom to AV2’s. P2 recalled that SP1 said that s/he had “no idea” that AV1 entered AV2’s bedroom and that s/he closed the door to AV1’s bedroom after making the bedroom check because AV1 asked him/her to.

· P1 said that the incidents with the AVs occurred a few months ago, but s/he recalled working with SP1 in January of 2024, when AV1 entered AV2’s bedroom. P1 did some of the bedroom checks on that date and said that s/he completed checks by shining a flashlight onto the ceiling of the bedrooms but did not shine the flashlight directly onto the sleeping youths. P1 was unaware that the youths were together in AV2’s bedroom until s/he saw the video of the incident, but it would have been easy for AV1 to hide in AV2’s bedroom because AV1 was small, and there were many places for him/her to hide in a facility bedroom. When P1 saw the video of AV1 leaving his/her bedroom, s/he thought that AV1 dropped to his/her hands and knees to crawl out of the bedroom as soon as SP1 started to close the bedroom door and thought that SP1 would have noticed AV1 opening the door to crawl from his/her bedroom to AV2’s bedroom. According to P1, SP1 looked down at AV1 as SP1 was closing the door.

· SP1 did not complete an interview with this investigator, but information s/he provided in the Internal Review showed that SP1 thought s/he completed bedroom checks on the date of the incident and thought the AVs were asleep in their beds. SP1 saw AV1 and AV2 each use the restroom at separate times during the overnight shift but did not think anything of it and did not see AV1 leave his/her bedroom or enter or leave AV2’s bedroom. SP1 felt that s/he was not adequately trained and was “just kind of put on shift.”

· P2 said that staff persons were to check on youths in their bedrooms four times an hour in a staggered pattern, by shining a flashlight on the youths to ensure they were in their beds and breathing. P1 was in the facility office, possibly doing a medication count when AV1 left his/her bedroom, but P1 completed some of the checks on the youths in their bedrooms during the approximately two-hour period that the AVs were together in AV2’s bedroom. However, P1 did not use a flashlight to view the youths. P2 said that P1 told him/her that s/he forgot to use the flashlight but s/he could see the youths because they all had nightlights. P2 “wrote up” P1 and completed a “job coaching session” with him/her. P2 had no information whether AV1 placed items under his/her covers to make it appear that s/he was lying in his/her bed during the room checks and said that the AVs were not in AV2’s bedroom for the entire night.

The FMs were upset that the bedrooms of youths of all genders were located in close proximity to each other on the same wing of the facility. In addition, the FMs each stated that AV1 provided consistent information over time to them, that a staff person whose identity they could not recall, provided AV1 and other youths with vaping devices at the facility. The FMs thought that staff persons did not provide the youths with adequate supervision and stated that when they voiced their concerns to supervisory and administrative staff persons whose identities they could not recall at the facility, their concerns were minimized, and their telephone calls not returned.

The facility’s policy on Resident Supervision and Safety showed that staff persons were to supervise the residents and monitor resident movement to ensure and protect the health and safety of the residents. To determine the residents’ supervision needs, the facility considered referral information regarding the resident, a vulnerability and sexual abusive screen for the resident, and a comprehensive resident substance use disorder evaluation. When the need for one-to-one supervision was determined, a staff member was assigned to supervise the resident and that staff person was not considered a part of the staff ratio. During awake hours when residents were out of a staff person’s sight, staff persons were to complete a minimum of four random checks each hour not to exceed 20 minutes between checks. When residents were asleep, staff persons completed a minimum of four random checks each hour which must establish visual confirmation of the identity of the resident and breathing movement or other body movement,

Conclusion for Allegation One:

AV1 said that on the date of the incident, s/he and AV2 were unsupervised in AV2’s bedroom and had sexual intercourse. Information provided by P2 and P3 and video recordings from the facility showed that shortly after 1 a.m., on January 19, 2024, the AVs spent about one and a half hours together unsupervised in AV2’s bedroom. SP1 checked on AV1 in his/her bedroom, then when SP1 sat in the common area, AV1 crawled from his/her bedroom to AV2’s bedroom, using the couches in the common area to conceal him/herself.

SP1 and P1 checked on the AVs in their bedrooms during the period when the AVs were in AV2’s bedroom, but P1 did not consistently use a flashlight to make the checks. However, there were nightlights in the bedrooms, and it looked like the AVs were in their bedrooms. P1 thought that AV1 was small and could easily hide. The AVs provided conflicting information regarding whether they had sexual intercourse, but SP1 and P1 denied that they were aware of the AVs’ actions. The facility investigated the incident, moved the AVs’ bedrooms, and rearranged the furniture in the common areas to improve sight lines.

Although the AVs had sexual intercourse when they were unsupervised in AV2’s bedroom and a flashlight was not used on some of the bed checks, given that bed checks were done, and that no information showed that SP1 or P1 were aware that AV1 was in AV2’s bedroom, there was not a preponderance of the evidence as to whether staff persons were reasonably able to prevent the AVs from having unsupervised contact.

It was not 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; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Allegation Two: It was reported that on February 6, 2024, SP1 saw the AVs kiss, permitted the AVs to be unsupervised in a storeroom, and saw AV2 use a vaping device or smoke a “joint,” but took no action.

Facility documentation and interviews with this investigator provided the following:

· According to P3, while investigating the January 2024 incident and reviewing recordings from the video recording system, it was discovered that there were numerous concerns regarding SP1’s actions on February 6, 2024.

· AV1 said that SP1 let AV1 and AV2 into the facility storeroom on multiple occasions to use vaping devices and told them to use the storeroom so that the AVs would not be on camera using the devices. Staff persons let AV1 use vaping devices because they knew that s/he was addicted to nicotine.

· Facility documentation showed that starting at 12:07 a.m., on February 6, 2024, and multiple times during the overnight hours, the AVs used a cell phone (which the AVs were prohibited from having) and posted pictures of themselves to a social media application. The AVs were in a common area of the facility, and at 1:46 a.m., on February 6, 2024, SP1 opened the door to the storeroom and permitted AV1 and AV2 to enter the room together and remain there without supervision for about 34 minutes. At 2:23 a.m., AV1 sat on AV2’s lap in the common area, and there was “intimate touching” including kissing, rubbing, and “grinding” which was observed by SP1, who took no action. At 3:54 a.m., AV1 removed his/her pajama pants, which left him/her dressed in underwear and a shirt, then sat on AV2’s lap and rubbed his/her “bottom” on AV2 in the common area, who then took photos of AV1. SP1 was sitting at a table in the common area when these incidents occurred but did not intervene. The AVs used a vaping device at 3:34, 4:03, 4:17, 4:20, 4:22, and 5:48 a.m., and were seen blowing smoke into the air. At 4:23 a.m., the AVs entered the storage room again and remained in the room for approximately 45 minutes. At 5:13 a.m., the AVs again entered the storage room and remained there for about 35 minutes. The storage room door was closed on each occasion the AVs were in the room. SP1 witnessed each of these incidents but took no action.

· P3 immediately contacted SP1 to discuss the incidents, suspended SP1, and began investigating the incidents. The AVs’ bedrooms were moved and AV2 was relocated to a different floor of the facility. In July of 2024, AV1 and AV2 no longer resided at the facility, the videos were unavailable, and SP1 was no longer employed at the facility. No information showed that the AVs sustained an injury during the incidents.

· P1 was unaware of the incidents that occurred in February of 2024, and had no information that the AVs were permitted to be unsupervised in a storeroom, or that the AVs used a vaping device, but added that the AVs and other youths at the facility frequently obtained vaping devices and staff persons took many devices from the youths. P2 was not involved in the investigation of this incident.

· SP1 did not complete an interview with this investigator, did not provide information regarding these incidents to P3, and was not asked about them in the facility’s Internal Review.

Conclusion for Allegation Two:

A. Maltreatment:

AV1 said that SP1 permitted him/her and AV2 to use vaping devices at the facility and told them to use the devices in the storeroom so they would not be recorded by the facility’s video recording system.

P3 reviewed a video recording from the facility’s recording system which showed that on February 6, 2024, SP1 opened a storeroom door, permitted AV1 and AV2 to enter the room multiple times, and spend unsupervised time in the room. In the video, AV1 removed his/her pants, the AVs kissed and had other inappropriate physical contact, placed blankets on the storeroom floor, and then lay on the blankets. The AVs used a vaping device and blew smoke into the air. SP1 did not intervene with any of the incidents. In addition, the AVs used a facility cell phone and posted photos of themselves to a social media app.

AV1 had a history of using vaping devices and previously voiced concerns that s/he experienced nicotine withdrawal symptoms. The AVs were impulsive and AV2 had a history of making poor decisions which had negative consequences for him/her. After the incident, the AVs’ bedrooms were moved and AV2 was relocated to a different floor of the facility. In July of 2024, the AVs no longer resided at the facility, the videos were unavailable, and SP1 was no longer employed at the facility.

SP1 did not provide information regarding these incidents. However, AV1 said that SP1 let the AVs use the devices and information from P3 who reviewed the video recordings showed that SP1 permitted the AVs to have unsupervised and inappropriate contact at the facility and did not intervene when the AVs used a vaping device. Given this, that SP1 did not intervene and told the AVs to go into the closet to use the vape so they would be off camera, that the AVs were not of legal age to use or have vaping devices, the AVs’ vulnerabilities, and that SP1 was trained on the facility’s policies and procedures prior to the incidents, there was a preponderance of the evidence that SP1 did not provide the AVs with care that was required for their 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, or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

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.

SP1 was responsible for the care of the AVs when the incident occurred and was trained on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act prior to the incidents.

SP1 was responsible for maltreatment of the AVs.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP1 was responsible did not meet statutory criteria to be determined as recurring because his/her pattern of behavior was considered a single incident and was not serious because no information showed that the AVs were injured during the incident.

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

Allegation Three: It was reported that SP2 permitted AV1 to use SP2’s personal vaping device and brought vaping devices to the facility for AV1 to use.

Facility documentation, the facility’s Internal Review, and interviews with this investigator provided the following:

· AV1 said in an interview with this investigator, that SP2 brought vaping devices to the facility on multiple occasions for AV1 to use and let AV1 use his/her personal vaping devices. When one vaping device “ran out,” SP2 gave AV1 another vaping device to replace it. SP2 let other youths use vaping devices, but AV1 could not identify the other youths.

· SP2 said that s/he was familiar with these concerns, and they had been investigated by the facility in an Internal Review in January of 2024. SP2 said that s/he used vaping devices and occasionally used them in his/her personal car when s/he drove between locations on the facility campus. However, SP2 ducked in his/her car when using the devices to prevent youths on campus from seeing him/her. In addition, in January of 2024, AV1 and other youths asked SP2 and other staff persons to help them get vaping devices, but SP2 told the youths, “Of course not,” and declined to assist them to obtain vaping services and did not share his/her vaping devices with them. SP2 thought that a staff person (P4) provided the above inaccurate information about him/her because s/he felt animosity toward SP2 when s/he was promoted to a position for which s/he and P4 each applied.

· The facility’s Internal Review of the incident showed that on January 11, 2024, facility supervisory staff persons, including P2, received information that there was talk among the youths that SP2 permitted youths to use his/her personal vaping device in a facility office. In the Internal Review, SP2 acknowledged that s/he used vaping devices in his/her car at the facility, but the youths did not see him/her and SP2’s vaping device did not match the description of the device provided by the youths. SP2 denied that s/he provided the youths with vaping devices or that s/he allowed the youths to use his/her vaping device/s.

· In the Internal Review, information from AV1 showed that s/he talked about using vapes with another youth at the facility who told AV1 that SP2 gave the youth a vaping device in the past, but AV1 did not provide additional information.

· There were no cameras in the room in which the incidents were alleged to have occurred. Staff persons were instructed to do “pocket checks” on AV1 after each visit with his/her family members because there were concerns that AV1 obtained vaping devices from family members or while in the community. It was determined that the facility’s policies and procedures were not followed when SP2 used his/her vaping devices on campus but were adequate. SP2 was given coaching and a written corrective action for using substances on campus, and signed a substance use procedures acknowledgement form. The incidents were not similar to past events with the youths or SP2. The facility did not report this incident to the Department of Human Services.

Conclusion for Allegation Three:

Although AV1 told this investigator that SP2 provided him/her with vaping devices, given that statements from AV1 in the Internal Review showed that s/he had no first-hand information but relayed information from another youth, that there were no witnesses to the incident, and that SP2 denied that s/he gave vaping devices to AV1 or other youths, there was not a preponderance of the evidence as to whether SP2’s actions posed a risk to youths at the facility.

It was not 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; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Action Taken by Facility:

The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The facility planned that a supervisory staff person would work an overnight shift with SP1 and P1 individually to retrain them on shift expectations. Additional random video recording checks for SP1 and P1 were to be implemented, and all staff persons were instructed to remain within “close proximity” of the AVs to prevent future physical contact. The AV’s bedrooms were moved to decrease the opportunities for them to have contact. On February 12, 2024, SP1’s employment at the facility ended because of the allegations in this report and P1 left employment at the facility in April of 2024, for reasons unrelated to this report.

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 November 27, 2024, the facility was issued a correction order for not reporting suspected maltreatment as required.

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


report_date: November 12, 2024

raw_content:
November 12, 2024

Su-Fei Wong, Authorized Agent

7625 Metro Blvd Ste 200

Minneapolis, MN, 55439-3057

License Number: 1036848 (CRF)

Report Numbers: 202403642 and 202404736

CORRECTION ORDER

Dear Su-Fei Wong,

On July 15, 16 and 17, 2024, Department of Human Services (DHS) licensors conducted a licensing investigation at your facility, Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN. This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, chapter 2960. 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.

PRACTICES

1. Violation: One incident report reviewed for requirements governing critical incidents did not meet requirements. An incident dated June 3, 2024, met the definition of a critical incident and was not reported to the commissioner.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A.

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

2. Violation: Requirements governing clinical supervision were not met for one week reviewed. Seven staff persons that provided program services the week of June 23, 2024, did not attend a weekly clinical supervision meeting.

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

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

RESIDENT FILES

3. Violation: One resident file reviewed for requirements governing a variance to allow a resident admission to a program when their age is below what is stated on the CRF license did not meet requirements (R1). The variance required that DHS be notified of any incident within 24 hours. Thirty-one incidents occurred between March 29, 2024, and April 30, 2024, and were not reported as required by the variance.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 9.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure all conditions required by an approved variance to Minnesota Rules are met.

4. Violation: Two resident files reviewed for requirements governing standards for treatment in a locked setting did not meet requirements (R2 and R3). The individual treatment plan did not identify the following required components:

a. The need for treatment in a locked setting;

b. The relationship of treatment within a locked setting to the resident's overall treatment goals;

c. The treatment goals the resident must meet to have access to increased freedom of movement or be placed in a less restrictive appropriate treatment setting;

d. A plan for discharge from treatment in a locked setting to a less restrictive treatment environment when it is consistent with the resident's ability to be in a less restrictive environment.

Rule Violated: Minnesota Rules, part 2960.0700, subpart 1, item B.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans for treatment in a locked settings meets all applicable requirements. Within 30 days receipt of this order, submit an individual treatment plan that demonstrates compliance.

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Maddy Gilbertson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Questions

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

Sincerely,

Katie Leuer, Unit Supervisor

Licensing Division

Office of Inspector General

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


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.”

Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”

Report Number: 202308165

Date Issued: December 13, 2023

Name and Address of Facility Investigated:

Bar None Residential Facilities
22426 Saint Francis Boulevard
Anoka, MN 55303

Disposition: Maltreatment determined as to neglect of two alleged victims by a staff person.

Substantiated as to neglect of a vulnerable adult by a staff person.

License Number and Program Type:

1036848-CRF (Children’s Residential Facility)

Investigator(s):

Kimberly Huettl Anderson
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6553

kimberly.huett.anderson@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) allowed two alleged victims (AV1 and AV2) and one vulnerable adult (VA) use his/her nicotine vape pen on more than one occasion.

Date of Incident(s): September 22, 2023

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

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.

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a):

The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on October 27, 2023; from documentation at the facility; and through eleven interviews conducted with AV1, AV2, and the VA; facility staff persons, AV1’s guardian (G1), AV2’s guardian (G2), and the VA’s family member (FM), and the SP.

The facility provided residential care for adolescents in need of out-of-home placement.

AV1’s Client Info stated that AV1 was sixteen years old at the time of the incident and diagnosed with oppositional defiant disorder, attention-deficit hyperactivity disorder, cannabis dependence disorder, and alcohol dependence disorder. AV1’s Person Centered Treatment Plan stated that s/he was admitted to the facility for substance abuse and mental health concerns. Staff persons were to provide AV1 with coping skills to manage his/her mental health and substance abuse.

AV2’s Client Info stated that AV2 was fifteen years old at the time of the incident and diagnosed with Cannabis dependence, post-traumatic stress disorder, attention deficit hyperactivity disorder, and reactive attachment disorder. AV2’s Person Centered Treatment Plan stated that AV2 was admitted to the facility to address his/her nicotine, vaping, marijuana usage and to develop effective coping skills to manage his/her substance abuse and mental health concerns.

The VA’s Client Info stated that the VA was eighteen years old at the time of the incident and diagnosed with cannabis and nicotine dependence disorder, major depressive disorder, attention deficit hyperactivity disorder, and anxiety disorder. The VA’s Person Centered Treatment Plan stated that the VA was admitted to the facility for substance abuse and mental health concerns.

The facility’s Critical Incident Reporting Form stated that on September 22, 2023, the SP took AV1, AV2, and the VA on a walk and let AV1, AV2, and the VA use the SP’s nicotine vape pen.

AV1 told this investigator that on the day of the incident, AV1, AV2, and the VA went on a walk around the facility with the SP. When the SP pulled a nicotine vape pen out of his/her pocket, AV1, AV2, and the VA asked the SP if s/he would let them use it. The SP gave the nicotine vape pen to AV2 first and then AV2 gave it to AV1 and the VA. AV1 stated that s/he did not want to use the nicotine vape pen, but s/he did because s/he felt peer pressured.

AV2 did not want to talk to this investigator about the incident.

The VA told this investigator that s/he saw the SP share the nicotine vape pen with AV1 and AV2 but that s/he did not use it because s/he was discharging from the facility soon.

Two facility management persons (P1 and P2) and one staff person (P3) provided the following information:

· P1, P2, and P3 each stated that on the day of the incident, P3 brought a fourth resident on a walk to meet up with the SP, AV1, AV2, and the VA. When P3 and the other resident approached the SP, AV1, AV2, and the VA they smelled a blueberry scent. P3 did not recognize the smell but the other resident told P3 that it was a vape.

· P3 did not see the vape pen and did not talk to the SP about the incident but talked to P1 about it.

· P1 and P2 were not at the facility at the time of the incident, but P1 received a message from P3 about the incident that evening. The next morning P1 and P2 spoke to AV1, AV2, and the VA individually and asked them if the SP allowed them to smoke his/her vape pen. At that time, AV1, AV2, and the VA all denied smoking the vape pen.

· After talking to AV1, AV2, and the VA, P1 and P2 asked them to submit a urine analysis which came back positive for nicotine.

· P1 and P2 spoke to the SP on the day after the incident. The SP told P1 and P2 that s/he gave his/her vape pen to AV1, AV2, and the VA and allowed them to use it when they were on a nature walk. P2 stated that the SP also said that s/he allowed AV1, AV2, and the VA to use his/her vape on one other occasion but did not provide any details about when the other incident occurred.

· P1 and P2 did not know how many times that AV1, AV2, and the VA used the SP’s vape pen. P2 stated that many of the youth tested positive for nicotine because vape pens were easily accessible to them. P1 and P2 each stated that it was not uncommon for the VA’s urine tests to be positive for nicotine because the VA admitted to using nicotine when s/he was on home visits.

· The facility prohibited all drugs and alcohol on the premises except for nicotine for staff persons. However, staff persons were to keep their cigarettes or vape pens in their car and use them off site if they required a “smoke” break.

· P1 and P2 each stated that the SP was trained on the facility’s drug and alcohol policies, on professional boundaries, and on AV1’s, AV2’s, and the VA’s treatment plans prior to the incident.

The SP provided the following information:

· On September 22, 2023, the SP went on a nature walk around the facility with AV1, AV2, and the VA. When they entered a wooded area, AV1, AV2, and the VA asked if they could use the SP’s vape pen. The SP stated that s/he felt “ganged up on” so s/he let them take “several hits” of the vape pen.

· AV1, AV2, and the VA each knew that the SP carried his/her vape pen in his/her pocket because they saw the SP carrying it in his/her hand. The SP stated that s/he was trained to keep the vape pen in his/her vehicle, but that s/he felt that keeping the vape pen in his/her pocket was “safer.”

· When P1 and P2 asked the SP if s/he allowed AV1, AV2, and the VA to use his/her vape pen, s/he acknowledged that s/he had let them use it on more than one occasion. The SP told this investigator that AV1, AV2, and the VA each used the SP’s vape pen on three separate occasions.

· The SP was aware that AV1, AV2, and the VA struggled with substance abuse and that they were at the facility to receive substance abuse treatment, but the SP did not consider nicotine a drug.

G1 stated that s/he was aware of the incident involving the nicotine vape pen but did not have any other concerns about the facility.

G2 was concerned about the incident involving AV2 using the SP’s nicotine vape pen as well as being concerned about the lack of communication from facility management persons regarding AV2’s progress at the facility.

The FM was concerned that the SP allowed the VA to use his/her nicotine vape pen when the VA was at the facility for substance abuse.

The facility’s Cumulative Reports for AV1, AV2, and the VA’s urine analysis dated September 3 and October 22, 2023, provided the following information:

· AV1 was positive for nicotine on September 5, 15, 22, and 23, 2023.

· AV2 was positive for nicotine on September 5, 15, and 22, 2023.

· The VA was positive for nicotine on September 3, 5, 10, 15, 18, 22, 24, and 29, 2023.

The facility’s Smoking/Tobacco Use policy stated that residents and staff persons were “never” allowed to use tobacco on the facility’s property or during facility activities. Facility staff persons were to keep tobacco concealed within a vehicle or the back office and not within a residents’ access. Facility staff persons were prohibited from providing the tobacco products to residents.

The facility’s personnel files showed that the SP was trained on the facility’s Smoking/Tobacco Use policy on July 17, 2023. The SP, P1, P2, and P3 were each trained on the Reporting of Maltreatment of Minors Act and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident.

Relevant Rules and/or Statutes:

Minnesota Statute, section 609.685 states in part that persons under the age of 21 can not be sold, given, or otherwise furnished tobacco, tobacco-related devices, or electronic delivery devices.

Conclusion:

A. Maltreatment:

On September 22, 2023, the SP, AV1, AV2, and the VA went on a walk and AV1, AV2, and the VA took “several hits” off of the SP’s vape pen. The SP also told P1 and P2 that s/he allowed AV1, AV2, and the VA to use his/her vape pen on more than one occasion and told this investigator that s/he allowed them to use it on three separate occasions.

AV1, AV2, and the VA each had a history of substance use and were at the facility in part to develop coping skills to address their substance use. Although the SP did not consider nicotine a drug, providing nicotine to AV1 and AV2 who were minors, and to the VA who was considered underage constituted an illegal act and encouraged each to engage in illegal activities, therefore there was a preponderance of the evidence that there was a failure to provide AV1 and AV2 with necessary care and that there was a failure to provide the VA with care that was reasonable and necessary.

It was determined that neglect occurred (failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical or other care required for the child’s physical or mental health when reasonably able to do so and 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).

It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

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

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

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

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

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

The SP was responsible for the care of AV1, AV2, and the VA. The SP was trained the facility’s Tobacco/Smoking policy, the Reporting of Maltreatment of Minors Act, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of AV1, AV2, and the VA.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which the SP was responsible was not serious because AV1, AV2, and the VA did not sustain an injury requiring medical care, but was considered recurring maltreatment because s/he stated that s/he allowed AV1, AV2, and the VA to use his/her vape pen on three occasions.

The SP was disqualified from providing direct contact services.

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

Action Taken by Facility:

The facility completed an internal review and determined that their policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility.

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

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

Certification:

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

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


report_date: August 2, 2023

summary: CORRECTION ORDER

raw_content:
August 2, 2023

Su-Fei Wong, Authorized Agent

7625 Metro Blvd Ste 200

Minneapolis, MN 55439

RE:  Report No. 202210371

Bar None Residential Services

License No. 1036848

Dear Su-Fei Wong:

CORRECTION ORDER

An investigation of Bar None Residential Services was completed regarding report number 202210371 which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegation concerned physical abuse and neglect. The disposition of the investigation report is maltreatment determined. Two violations were noted.

VIOLATIONS AND CORRECTION ORDERS

The following violations of state and (or) federal laws and rules were observed. Corrective action for each 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 2960.0050, subpart 1, items N and R; and 2960.0710, subpart 6, items A and B.

Violation: The license holder did not ensure that an emergency use of physical holding was in response to an immediate intervention necessary to protect the resident or others from physical harm; and that the physical holding used was the least intrusive intervention that would effectively react to the emergency. This resulted in a violation of the resident’s 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.

· On December 1, 2022, staff (S) implemented an emergency use of physical holding on a child (C2) that was not in response to an imminent threat of harm; and instead, the C2 came out of his/her room during a “Five Second Rule.” (Note: This is called to get all residents into their rooms in five seconds so staff persons can address a situation.) and S grabbed C2 by the shirt and pinned him/her to the door. Through interviews with C2 and other staff members it was determined S did not attempt lesser restrictive methods prior to implementing the physical hold.

· On December 15, 2022, staff (S) implemented an emergency use of physical holding on a child (C3) that was not in response to an imminent threat of harm; and the technique used was not part of the license holder’s approved restrictive procedures plan. The physical hold was implemented after C3 threw a deck of cards at others and the S grabbed C3’s sweatshirt at the neck and pushed C3 backwards and over a couch. Through interviews with C1 and other staff members it was determined S did not attempt lesser restrictive methods prior to implementing the physical hold and did not use an approved restrictive procedure.

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

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, Ginny Benson at 651-431-6957.

Sincerely,

Scott Broady, Investigator

Office of Inspector General

Licensing Division

Scott.broady@state.mn.us

651-431-6557

Enclosure

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