facility_name: Northwood Childrens Services Inc

summary: On December 2 through 5, 2024, Department of Human Services (DHS) licensors conducted licensing reviews at your facilities, Northwood Children’s Services-Main Campus located at 714 W College Street, Duluth, MN 55811 and Northwood Children’s Services, located at and 4000 W 9th Street, Duluth, MN 55807.


state: MN

facility_name: On-Belay House

report_date: August 8, 2025

raw_content:
PUBLIC

Summary of Settlement Agreement

License Holder: On-Belay of Minnesota, Inc.

License Number: 800099

Program Type: Children’s Residential Facility

Date of Licensing Action: August 8, 2025

Licensing Action Taken: Order of Revocation

Action appealed and settlement agreement signed by Commissioner on: November 19, 2025

Terms of Settlement Agreement:

Applicant withdraws appeal and surrenders license. DHS will not impose Order of Revocation. License Holder’s Authorized Agent may continue to operate and remain as authorized agent and controlling individual for license numbers 1038850 and 800098 under specified conditions.

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

doc_type: Order


raw_content:
August 8, 2025                    CERTIFIED MAIL

Jack Benson, Authorized Agent

On-Belay of Minnesota Inc

115 Forestview Ln. N

Plymouth, MN 55441

License Number  800099 (CRF/CD)

Report Numbers:   202500497

202504366

ORDER OF LICENSE REVOCATION

Dear Jack Benson:

The Department of Human Services (DHS) is revoking your license to provide chemical dependency treatment services in a children’s residential facility (CRF) at 115 Forestview LN N, Plymouth, MN 55441. This revocation is based on your noncompliance with licensing laws and rules governing the provision of chemical dependency treatment in children’s residential facilities (CRF), conditional license violations, and the Commissioner’s evaluation of the program. Details of our findings are provided below. Our next steps and your options are also detailed.

The revocation goes into effect on August 21, 2025, at 5:00 pm to allow time for delivery of this order and ten days for you to inform the Commissioner whether you intend to appeal the license revocation explained below.

REASON FOR LICENSE REVOCATION

1.  Commissioner’s evaluation of program

In determining whether a licensing action is warranted, DHS evaluated the facts, conditions, and circumstances concerning your program’s operation. This includes consideration of the well-being of children served by your program, and information about the qualifications of staff persons that are working in your program. DHS has determined that revocation of your license is appropriate based on the violations identified below and the program evaluation.

Your program has demonstrated a consistent pattern of noncompliance over a period of approximately three years, and DHS cannot be assured that you have the ability to meet the minimum standards required to provide children’s residential chemical dependency treatment services. DHS issued the initial conditional license on January 31, 2023, after significant non-compliance with regulatory standards. As part of the conditional status, DHS conducted a modified licensing review and investigation on October 2 through 4, 2023 and cited eighteen licensing violations in a correction order dated December 4, 2023. A correction order was issued on April 23, 2024, with one violation cited, when DHS determined you did not comply with a term of the conditional license requiring you self-monitor your compliance with applicable rules and statutes. When DHS conducted a full licensing review on August 21 through 23, 2024, thirty licensing violations were cited and the conditional status of your license to provide children’s residential chemical dependency treatment services was extended for an additional year, beginning January 31, 2025.

A significant portion of the violations determined in the May 28-30, 2025, licensing review poses risks to the health and safety of individuals served. An increase in the number and chronicity of licensing violations demonstrates that you are unable to ensure there is adequate oversight of your program, to ensure compliance with minimum standards.

You have demonstrated that you are unable to implement and sustain the necessary action steps to achieve or maintain compliance. While license holders providing children’s residential chemical dependency treatment services are required to maintain a qualified program director to oversee treatment services for clients and to supervise staff, your organization is structured in such a way that key positions, like the program director, report to you as the owner; in addition to you being the authorized agent. Throughout the licensing review, you ascribed the responsibility to ensure compliance with applicable requirements to individual staff persons other than yourself, who have not been able to move your program into compliance.

Based on the Commissioner’s evaluation of the program, revocation is warranted.

Legal Authority: Minnesota Statutes, section 245A.04, subdivision 6.

2. Conditional license violations

On May 28, 2025, DHS determined that you did not follow 2 of 4 terms of the Order of Conditional License that is in place from January 31, 2025, to January 31, 2026.

Term #1: The conditional license requires that you notify all current clients of the conditional status. In two of ten resident files reviewed, there was no documentation to demonstrate the required notice was provided.

Term #2: The conditional license requires that the program’s Compliance Officer does not hold another position of Program Director, ADC, ADC Supervisor, or any other position providing direct care services and that they allocate 75 percent of their working hours to the duties of Compliance Officer at the licensed program. During the on-site licensing review and investigation on May 28 and 29, 2025, DHS observed the Compliance Officer was also holding the position of Program Director. Noncompliance with term 2 of the conditional license occurred from January 31, 2025, until present.

Legal Authority: Minnesota Statutes, sections 245A.06, subdivision 3; and 245A.07, subdivision 3(a).

3.  Noncompliance with licensing laws and rules

On May 28 through May 29, 2025, DHS licensors conducted a licensing review and investigation at your facility located at 115 Forestview LN N, Plymouth, MN 55441. As a result of this licensing visit, DHS determined your program failed to comply with the laws and rules that apply to licensed children’s residential facilities providing chemical dependency treatment and cited 23 violations.

DHS has considered the nature, chronicity, or severity of the violations of law or rule and the effect of the violations on the health, safety or rights of persons served by the program. Based on this analysis, the Commissioner has determined that a revocation order is appropriate.

Nature and severity of licensing violations determined

Many of the violations cited in the Order of Revocation are violations impacting the health, safety, or rights of individuals served by the program:

· Four violations related to your ability to protect resident rights and to meet resident needs were determined (violations numbered 1, 2, 5 and 6). Children in your care deserve to have adults provide positive and proactive guidance and supervision, and there have been multiple incidents that were not adequately addressed. Your inability to protect the rights of vulnerable children in your care presents a risk of harm and is a significant violation;

· Three violations related to staff training were determined (violations numbered 15, 16, 17). You were unable to show DHS that all staff were trained on how to report maltreatment and the special needs of the population. These training requirements are a critical component in ensuring the safety of children and youth in your care.

· Two violations related to health services were determined (violations numbered 7 and 8). A critical responsibility of those providing residential care for children is to ensure their health and safety, and you did not ensure a medically licensed person had adequate oversight of these processes. Noncompliance with these minimum standards could result in significant health implications.

· Two violations related to background studies was determined (violations numbered 3 and 4 ). Noncompliance with background study requirements is a serious violation. Allowing individuals to work in a facility providing services to children before the required notice was received poses a risk of harm to children in your care. The inability to follow background study requirements calls into question the program’s ability to follow the applicable laws and rules and to ensure the well-being of children in your care.

· Two violations related to maltreatment of a vulnerable adult were determined (violations numbered 12 and 17). Assessing a vulnerable adult to determine if there are specific measures above and beyond the program abuse prevention plan is crucial to ensure their health and safety. Ensuring staff are trained on how to report maltreatment of a minor and vulnerable adults is a critical step in ensuring the license holder takes the appropriate action to protect children and youth from abuse and neglect.

· Two violations related to treatment planning were determined (violations numbered 9 and 10). The treatment planning process is a critical component of providing chemical dependency treatment services. All eight treatment plans reviewed did not meet the minimum standards, which is significant. For one resident, you did not develop a treatment plan at all, and for others, their plans were never updated. These deficiencies limit the likelihood that children in your care successfully complete treatment, which could possibly result in legal consequences or impact their willingness to engage in future treatment services.

· One violation related to maintaining a facility in good repair was determined (violation numbered 13). Children requiring residential treatment services deserve to have a clean, safe environment in which they can focus on their treatment and recovery. You have demonstrated an inability to ensure that basic maintenance tasks are completed in a timely manner.

· One violation related to discharging youth who have not yet met their treatment plan goals was determined (violation numbered 11). The no-eject process is in place to ensure children are not unnecessarily discharged without a complete review involving multiple parties. This process was not followed in six of nine resident files reviewed. Children placed in residential facilities benefit from stability in relationships and it can be harmful to move a child from place to place without resolving the reason they were placed in out of home care.

Chronicity of licensing violations determined

Your program received its license to provide children’s residential chemical dependency treatment services on February 4, 1980. In calendar year 2019, the program director who had provided oversight for approximately nine years changed. Since calendar year 2019, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes the last five years:

o July 9, 2025 Order of License Revocation (this order):    23 violations, 17 repeat

o October 21, 2024 Order Extending a Current Conditional License   30 violations, 23 repeat

o December 4, 2023 Licensing review correction order     18 violations, 13 repeat

o August 12, 2022 Order of Conditional License       30 violations, 20 repeat

o June 16, 2020 Licensing Review Correction Order       30 violations, 11 repeat

o May 19, 2020 Background Study Fine Order (Health and Safety)

Non-compliance with conditional terms noted in the following orders:

o July 9, 2025, Order of License Revocation (this order)

o May 6, 2025 Fine Order

o April 23, 2024 Correction Order

Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3(a)(1).

Due to the serious and chronic nature of these violations and the conditions in the program, which impact the health and safety of children in your care, your license to provide children’s residential chemical dependency treatment services is revoked.

LICENSING VIOLATIONS DETERMINED ON MAY 28 - 30, 2025

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

1. Violation: The license holder did not meet the needs of residents and ensure resident rights were protected in the following ways:

a. The license holder did not ensure the right to proactive adult guidance, support, and supervision was protected or responded in a manner that would meet the needs of the residents:

1. During a licensing investigation, DHS determined through review of resident files and program documentation and resident and staff interviews, that significant incidents involving inappropriate sexual conduct occurred.

i. On February 9, 2025, two residents (R11 and R12) were lured by another resident, with the promise of receiving substances to use, into a bedroom where other residents from the program had already gathered and at which time two other residents proceeded to physically attempt to remove the two lured residents pants and pour baby oil down their rear backsides.

ii. On January 11, 2025, a resident (R1) proceeded to walk in and out of the shower room, nude, exposing their genitals, while making threats to their peers.

iii. On January 6, 2025, a resident (R1) was observed with their hands down their pants, stimulating themselves, while sitting in a group with other residents watching.

b. The license holder did not adequately supervise residents in the program. DHS determined the license holder did not ensure that there were enough staff persons present to meet the needs of the residents based upon the following ongoing occurrences:

1. Residents absconding from the program on November 1 and 25, 2024, December 7, 2024, January 8 and 9, 2025, March 13, 22, 24, and 27, 2025, April 4, 2025, and May 3, 2025;

2. Residents accessing and using substances in the program on November 17 and 18, 2024, December 1, 16, 26, 27, and 30, 2024, January 14 and 15, 2025, March 7 and 19, 2025, April 15, 2025, and May 1, 2025;

3. Incident reports reviewed that indicate physical altercations and/ occurring on February 16, 2025, March 9, 2025, and March 13, 2025;

4. Staff not knowing the whereabouts of residents, on December 31, 2024, when three residents were reported as missing from the program; however, less than an hour later they were found to have been in the game room the entire time;

5. On February 16, 2025, a staff person walked away from their duties of supervising the residents and providing services, including administering medications, stating that they could not manage all of the residents behaviors, meanwhile the other staff person on shift had no indication of what was going on as they were in another part of the facility making breakfast for all of the residents;

c. The license holder did not ensure a resident right to a reasonable degree of privacy. Through resident and staff interviews and review of resident file documentation it was determined that the license holder did not adequately supervise or provide privacy to residents use of the program’s bathroom facilities. DHS determined there were ongoing occurrences of residents entering the bathroom while other residents were already present, either showering or using the toilet stalls, and either invaded the resident’s privacy or threatened to do so without a staff person’s knowledge, resulting in reports of residents not feeling safe to use the bathroom.

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 1, item D, and 2960.0100, subpart 6.

2. Violation: The license holder did not ensure the residents right to the rights stated in Minnesota Statutes, section 144.651, were protected. DHS determined through reviewing documentation and resident and staff interviews that residents were required to complete daily “chores” by cleaning multiple areas of the building. There was no documentation to demonstrate this was therapeutic or consistent with resident’s treatment plans. Minnesota Statutes, section 144.651, subdivision 23, prohibits residents from performing labor or services for the facility unless those activities are included for therapeutic purposes and consistent with the residents’ treatment plan.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 2, 2023

3. Violation: As a result of a licensing review, a DHS licensor determined that the license holder did not comply with background study (BGS) requirements in the following ways:

a. The license holder did not comply with the set aside notice for staff person (SP11). The set aside was issued to a specific license (license number 1038850), and the license holder allowed them to work at another of their licensed programs (license number 800099).

Set asides are issued to a specific license and are based on the specifics of the staff person and the people they will provide direct contact to at the specific licensed program. License holders may not affiliate a staff person across all of their licenses without set aside approval for each license.

b. The license holder permitted staff person (SP8 and SP10 through SP13) to begin working in the children’s residential facility, before a BGS notice was issued for the following:

1. SP8 was hired and began working in the children’s residential facility on April 19, 2025. However, the BGS notice was not issued until April 23, 2025;

2. SP10 was hired and began working in the children’s residential facility on February 4, 2025. However, the BGS notice was not issued until February 7, 2025;

3. SP11 was hired and began working in the children’s residential facility on April 14, 2025. However, the BGS notice was not issued until May 22, 2025;

4. SP12 was hired and began working in the children’s residential facility on March 19, 2025. However, the BGS notice was not issued until March 20, 2025; and

5. SP13 was hired and began working in the children’s residential facility on March 19, 2025, at 12pm. However, the BGS notice was not issued until March 19, 2025, at 7:47pm.

Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 11, 245C.13, subdivision 2, and 245C.22, subdivision 5.

Repeat Violation: The license holder was previously found in violation of this same statute in Order(s) that DHS issued on:

· October 21, 2024

· August 12, 2022

4. Violation: Ten of ten personnel files reviewed for requirements governing background study documentation in a children’s residential facility did not meet requirements in the following ways:

a. The license holder did not document the first date that a staff person began working in the license holder’s facility or setting (SP8, SP11, and SP12); and

b. The license holder did not document the first date that a staff person had direct contact, as defined in section 245C.02, subdivision 11 (SP1 and SP6 through SP14).

Statute Violated: Minnesota Statutes, section 245A.041, subdivisions 5 and 6.

5. Violation: The license holder did not meet requirements governing disciplinary procedures in the following ways:

a. The license holder utilized an unapproved disciplinary procedure. The disciplinary procedure identified as Room Restriction, required residents to go to their bedrooms and remain there in response to an undesirable or unacceptable behavior. Resident and staff interviews with residents and staff and review of resident file documentation identified the use of Room Restriction on March 17, 2025 (R6), April 1, 2025 (R2) and April 21, 2025 (R2). Minnesota Rules, part 2960.0080, subpart 5, item D, allows for the use of “time-out”, if the license holder maintains a time-out policy and ensures staff are trained prior implementing time-out. The license holder did not have a time-out policy and staff were not trained prior to the use of Room Restriction;

b. Disciplinary actions used by the license holder subjected residents to the withholding of basic needs and did not protect a residents right to reasonable communication and visitation with adults outside the facility. Interviews with residents and staff and review of resident file documentation identified the following:

1. The use of the license holder’s Family Visit Pass Rubric resulted in the cancellation of a resident’s family visit on April 17, 2025 (R7). The rubric determined a residents’ eligibility for a family visit based upon their behavior and participation in treatment groups, and did not allow a resident to earn a family visit for at least the first 60 days the resident was in the program; and

2. A resident was not allowed to make a phone call to their parents on April 21, 2025, because they were on a Room Restriction (R2). Restricting the residents’ communication was not specified in their treatment plan; the restriction was utilized as a disciplinary action; and

c. Documentation of the facility rules provided to residents did not include the use of Room Restriction or the Family Visit Pass Rubric as a disciplinary procedure or consequence to be applied in modifying unacceptable behavior.

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 1, item J, and 2960.0080, subparts 4, items B and C, and 5.

6. Violation: The license holder’s documentation did not demonstrate that at least one direct care staff was present for every twelve residents during awake hours for the following dates:

a. March 29, 2025;

b. March 15, 2025; and

c. February 15, 2025.

Rule Violated: Minnesota Rules, part 2960.0150, subpart 3, item G.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· December 4, 2023

· August 12, 2022

7. Violation: There was no documentation to demonstrate that a medically licensed person provided consultation and review of the license holder’s administration of medications at least monthly for the following months reviewed:

a. December 2024 and January 2025 (R1); and

b. March, April, and May 2025 (R2).

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

8. Violation: Two of two resident files reviewed for requirements governing health services did not meet requirements in the following ways:

a. The license holder did not maintain a record of the action taken for the following:

1. When a resident (R2) reported several instances (April 8, 9, 10, 19, 20, and 22, 2025, and May 10 and 16, 2025) of a medical concern (stomach distress and skipping meals); and

2. When a resident (R1) was observed by staff to be physically ill from suspected substance use on November 17, 2024;

b. The license holder did not complete medication verification upon admission for a resident who admitted with prescribed medications (R2);

c. The quantity of medications initially received from the pharmacy was not documented (R1 and R2); and

d. The medication administration record contained several blank entries in the months of December 2024 and January 2025 (R1) and in the months of March, April, and May 2025 (R2). Therefore, the amount and dosage of medication given, the time the medication was taken and whether a resident refused to take a prescription medication was unable to be determined for the prescribed medications on the medication administration record.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· August 12, 2022

9. Violation: Eight of eight resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways:

a. The plan was not developed within 10 days of admission or began upon the completion of the comprehensive assessment (R1 and R2);

b. A treatment plan was not developed (R7). The resident was admitted to the program for three months and there was no plan in place identifying how residential treatment services were to be provided, or how to address behavioral concerns that arose during the residents treatment episode;

c. The plan did not continually evolve based upon new information gathered about the resident’s condition (R1, R2, R5, and R6);

d. The participation of others was not noted in the plan (R2);

e. The objectives were not specific and individualized (R1 and R2); and

f. Specific intervals for which resident progress was to be reviewed was not included in the plan (R1 and R2).

Rule Violated: Minnesota Rules, parts 2960.0180, subpart 2, item B, 2960.0490, subparts 1, 2, and 3, items C and D.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

10. Violation: Two of two resident files reviewed for requirements governing treatment plan reviews and treatment services did not meet requirements in the following ways:

a. The treatment plan was not reviewed at least every two weeks from April 17, 2025, through May 5, 2025 (R2);

b. Specific services did not change when expected outcomes were not being achieved (R1 and R2);

c. A resident was not provided at least 15 hours of chemical dependency treatment services for the week of April 6, 2025. Documentation demonstrated a total of 11 hours of treatment services was provided (R2); and

d. A resident was not provided individual counseling for the week of November 17, 2024, as identified on their individual treatment plan (R1);

e. There was no documentation to demonstrate a resident was provided, at least weekly, living skills development, including employment/educational services to assist the resident in becoming financially independent, as indicated in the resident’s treatment plan for the weeks of November 17, 2024, and December 29, 2024 (R1) and April 6, 2025, and May 18, 2025 (R2); and

f. There was no documentation of the type and amount of each service the resident received weekly (R1 and R2).

Rule Violated: Minnesota Rules, parts 2960.0450, subparts 2, item B, and 3, item C, and 2960.0490, subparts 4 and 5.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

11. Violation: Six of nine resident files reviewed for requirements governing no eject discharges did not meet requirements (R1, R2, R6 through R8, and R10). Documentation did not demonstrate the following was completed before the license holder discharged a resident who had not yet reached their treatment plan goals:

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

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

c. When the discharge was warranted, the reasons for the discharge and the alternatives considered or attempted were not documented.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· August 12, 2022

· June 16, 2020

12. Violation: One resident file reviewed for requirements governing the individual abuse prevention plan (IAPP) did not meet requirements in the following ways (R3):

a. The license holder did not identify detailed measures to be taken to minimize the risk that the vulnerable adult might reasonably be expected to pose to visitors at the facility and persons outside the facility, if unsupervised, for a vulnerable adult, who the facility was aware, had committed a violent crime or an act of physical aggression towards others; and

b. There was no documentation to demonstrate the interdisciplinary team reviewed and evaluated the IAPP as part of the treatment plan reviews.

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

Repeat Violation: The license holder was previously found in violation of this same statute in Order(s) that DHS issued on:

· October 21, 2024

· August 12, 2022

· June 16, 2020

13. Violation: The license holder did not ensure that maintenance and housekeeping services were operated on a consistent basis to ensure the facility was kept in good repair. A DHS licensor observed broken wall and heating vents, broken toilet stall locks, a broken window, stained pillows, and mold and grime in the kitchen sink. The program maintenance log identified numerous maintenance and housekeeping needs since January 2025 that had not yet been completed.

Rule Violated: Minnesota Rules, parts 2960.0110, subpart 3, item A, and 2960.0200, item A.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

14. Violation: One personnel file reviewed for requirements governing supervision of an individual with a temporary permit (SP11) did not meet requirements. The file did not contain documentation to demonstrate that the staff person had received supervision at least weekly, since September 11, 2024.

Rule Violated: Minnesota Rules, part 2960.0460, subpart 6a, item A.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

15. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways (SP6 through SP8):

a. The license holder was unable to demonstrate that the staff person received orientation to the following topics before having unsupervised contact with residents:

1. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment

2. Maltreatment of Minors reporting requirements under Minnesota Statutes, sections 260E;

3. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues;

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

5. Operational policies and procedures;

b. Documentation did not demonstrate the staff person received orientation to data practices regulations before having unsupervised contact with residents; and

c. Documentation did not demonstrate the staff person received orientation to sexual orientation issues.

Rule Violated: Minnesota Rules, parts 2960.0100, subpart 3, item A, and 2960.0150, subpart 4, item C.

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

16. Violation: Five of five personnel files reviewed for requirements governing training did not meet requirements (SP1, SP2, and SP6 through SP8). There was no documentation to demonstrate the staff person received training related to their duties in implementing the programs policies and procedures.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b).

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

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

a. Documentation did not demonstrate the staff person received ongoing training to:

1. Topics including meeting the needs of residents and skill development (SP2 through SP5);

2. Vulnerable adult maltreatment reporting requirements and definitions in sections 626.557 and 626.5572, annually (SP5);

3. All internal policies and procedures related to the prevention and reporting of maltreatment of adults receiving services, annually (SP2 through SP5);

4. Maltreatment of Minors reporting requirements under Minnesota Statutes, sections 260E, annually (SP5); and

5. At least 24 hours of in-service training for the annual year (SP2 through SP5); and

b. Documentation did not include the dates and the name of the entity/person(s) providing the training for each topic area (SP2 through SP5).

Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3; Minnesota Rules, parts 2960.0100, subpart 3, items A and B, and 2960.0150, subpart 4, item C.

Repeat Violation: The license holder was previously found in violation of this same statute and rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

18. Violation: Two of two resident files reviewed for requirements governing admission criteria did not contain documentation of the license holder’s determination before or at admission of whether:

a. The resident was a danger to themselves or others (R1 and R2); and

b. The program was able to meet the resident’s cultural, emotional, educational, mental health, and physical needs (R2).

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

19. Violation: Two of four resident files reviewed for requirements governing the initial services plan (ISP) did not meet requirements. The ISP did not include:

a. Suggestions for the client during the time between intake and the first treatment session (R1 and R2); and

b. The issues that are to be addressed in the first treatment sessions (R1).

Rule Violated: Minnesota Rules, part 2960.0485.

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

a. The health screening was not completed (R2);

b. The mental health screening was not completed (R1); and

c. There were no documented inquiries and results of the inquiries regarding the degree to which the resident’s family desired to be involved during the resident’s stay in the facility (R1 and R2).

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

21. Violation: The license holder’s emergency plan did not meet requirements. The license holder is a children’s residential chemical dependency treatment facility and the emergency plan did not include any specific actions to be taken by the staff and residents nor any specific responsibilities the license holder must assume for assisting a resident who requires emergency care or any other emergency or law enforcement response due to a resident’s substance use in the facility, including intoxication, overdose, drug paraphernalia, etc.

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

22. Violation: One of four personnel files reviewed for requirements governing the emergency plan did not meet requirements (SP) The license holder did not review the facilities emergency plan once at least every six months for calendar year 2024.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

· June 16, 2020

23. Violation: The license holder did not meet critical incident reporting requirements. Incidents that occurred on the following dates met the definition of a critical incident and were not reported to DHS:

a. March 27, 2025;

b. March 13, 2025;

c. March 9, 2025; and

d. February 1, 2025

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

Repeat Violation: The license holder was previously found in violation of this same rule in Order(s) that DHS issued on:

· October 21, 2024

· December 4, 2023

· August 12, 2022

License holders determined to have a background study violation are required to pay a $200 fine for each violation. Because license revocation is a more severe sanction against your license, DHS is not imposing this fine.

YOUR RIGHT TO APPEAL

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

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order. If you do not appeal or if the order is affirmed by the Commissioner following a hearing, DHS is prohibited from issuing you and the controlling individuals a license for five years. In addition, any additional licenses held by you or the controlling individuals shall also be revoked.

Legal representation at the contested case hearing:

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

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

Operating the program pending the outcome of the appeal:

If you file an appeal within the timeframes described above, you may continue to operate pending the outcome of your appeal. If you continue to operate, you must comply with the conditions described below. If you continue to operate, you must do so in full compliance with all licensing laws and rules. Failure to follow a law or rule that may impact the health or safety of children served by your program could result in the immediate suspension of your license.

If you continue to operate pending the outcome of your appeal, you must comply with the following conditions:

1. Within 14 days of filing an appeal, you must notify current residents, the resident’s parent/guardian, and all parties who refer individuals to your program of the status of your license: revoked operating under appeal. While operating pending appeal, you must notify new residents, the resident’s parent/guardian, and referral sources that the license is revoked and operating under appeal before they begin receiving services. A copy of the notice with the resident, parent/guardian and/or legal representative(s) signature must be maintained in the client file.

Within 7 days of filing an appeal, you must submit a draft of the required notice to your DHS Licensor for approval. The notice must include the reasons your license was revoked, and it must include either a copy of the Revocation Order or an offer to provide a copy of the order upon request.

2. Immediately upon filing an appeal, you must stop all use of Room Restriction and submit a plan outlining how you will monitor the ways in which the milieu is managed, to ensure this practice has ceased. Your plan must be approved by DHS Licensing.

3. Within 7 days of filing an appeal, you must submit a time-out policy that meets requirements of Minnesota Rules, part 2960.0080, subpart 5, item D, for approval. Within 30 days of DHS Licensing’s approval of your policy, you must submit documentation demonstrating all staff persons have received training on the implementation of time-out procedures.

4. Within 7 days of filing an appeal, you must ensure there are a minimum of two staff persons providing direct contact services at all times and during all shifts, including when a staff person may be pulled away to complete other duties, such as preparing meals.

Within 30 days of filing an appeal, submit a staff schedule and the corresponding paystubs demonstrating compliance with this condition.

5. Within 14 days of filing an appeal, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Program Director, Alcohol and Drug Counselor (ADC), ADC Supervisor, or any other position providing direct care services. The Compliance Officer must allocate 100 percent of their working hours to the duties of Compliance Officer at license number 800099.

The program’s Compliance Officer must meet the following minimum qualifications and must be approved by the program’s DHS Licensor:

a. 2 years of professional experience in the following:

i. A regulatory or compliance position; and

ii. Involved in direct care as a substance use technician or counselor;

iii. If applicable, the development and implementation of mental health or substance use disorder treatment planning in a DHS licensed Children’s Residential Facility under Minnesota Rules, chapter 2960;

b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and Minnesota Rules, Chapter 2960, Children’s Residential Facilities;

c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field.

Any changes to the compliance officer position must be approved by DHS Licensing for the duration of the “Revoked: Operating under appeal” licensing status.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 3, which describes under which conditions DHS may revoke a license.

· The timeline to appeal a revocation order is provided in Minnesota Statutes, section 245A.07, subdivision 3(b).

· “Controlling individual” is defined under Minnesota Statutes, section 245A.02, subdivision 5a.

· Minnesota Statutes, section 245.095 defines which programs administered by DHS are included in the exclusion provision, and further defines “excluded,” “individual,” and “provider.”

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4)(iv) states that license holders shall pay a $200 for each background study violation.

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

· If a license holder files a timely appeal of a revocation order, the license holder may continue to operate the program pending a final order of the appeal under Minnesota Statutes, section 245A.07, subdivision 1(b).

· Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (3), the commissioner shall not issue or reissue a license if the applicant, license holder, or controlling individual has had a license issued under this chapter revoked within the past five years.

· Under Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (5), when a license issued under this chapter is revoked under clause (1) or (3), the license holder and controlling individual may not hold any license under chapter 245A for five years following the revocation, and other licenses held by the applicant, license holder, or controlling individual shall also be revoked.

· Under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (b), the commissioner may include terms the license holder must follow pending a final order on appeal.

Questions

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

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

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


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June 3, 2025                   CERTIFIED MAIL

Jack Benson, Authorized Agent

On-Belay of Minnesota Inc

115 Forestview Ln. N

Plymouth, MN 55441

License Number: 800099 (CRF)

ORDER TO PAY A FINE

Dear Jack Benson:

The Department of Human Services (DHS) is ordering you to pay a fine of $400 for three violations at your Substance Use Disorder Children’s Residential Treatment Facility (CRF) at 115 Forestview LN N, Plymouth, MN 55441. On October 21, 2024, the Department of Humans Services (DHS) issued an order to extend your license to provide Substance Use Disorder Children’s Residential Treatment Services on conditional status for one year, beginning January 31, 2025. In addition to the required licensing rules and statutes, an Order Extending a Conditional License also includes terms that the license holder must comply with. The following violations were determined as a result of not complying with terms of the Conditional License. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

1.  Health and Safety Violation

As a result of continued conditional license monitoring, a DHS licensor determined that the license holder has failed to comply with Term 4 of the Extended Conditional License dated October 21, 2024.

Specifically, to date, the license holder has failed to submit a fully compliant policy and procedure manual for the following:

a. DHS Licensing’s initial review of the license holder’s revised policy and procedure manual found significant noncompliance. DHS Licensing met with On-Belay House leadership for four hours on February 13 and 19, 2025, to provide feedback on areas found out of compliance. A copy of the compliance-monitoring checklist with additional notes, and notes from previous meetings when DHS Licensing gave similar feedback was provided.

b. The license holder was allowed 4 weeks to revise and re-submit a fully compliant policy and procedure manual following the February 19, 2025, meeting. The review of the revised manual received on March 17, 2025, again found significant non-compliance, including in areas that previously met requirements. The following health and safety policies are currently out of compliance:

· Health and Hygiene, including the health services plan requirements, providing a resident timely access to medical, mental, and dental health care, and the safe storage and delivery of medicine developed in consultation with a medically licensed person;

· Emergency Plans, including fire protection and placement of fire hoses and extinguishers, and the responsibilities assumed by the license holder for assisting with emergency care of residents;

· Grievance Procedure, including who is authorized to resolve the initial complaint and that the resident will receive a response within five days;

· Basic Rights, including the applicable rights in Minnesota Statutes, section 144.651;

· Reporting a Death, including the specific reporting requirements for DHS;

· Emergency Overdose Treatment, including the specific mode of administration to be used

· Staffing Plan, including identifying staff assignments, resident supervision, and ratios;

· Program Abuse Prevention Plan (PAPP), including all components aside from mental functioning and the knowledge the license holder may have regarding previous abuse;

· Statement of Intended Use, including the license holder’s expertise and qualifications to provide services, primary needs of residents, and the services provided;

· Admission Criteria, including criteria that is consistent with the population and program services identified in the statement of intended use;

· Program Description, including program and treatment services offered and provided

· Treatment Plans and Service Plan Reviews;

· Classification Plan, including living unit assignment based upon the resident’s age, developmental level, gender, physical assaultiveness, delinquent sophistication, and run risk;

· Rules, including the consequences that will be applied for modifying unacceptable behavior, the due process system, and the policies and procedures governing visiting, grievances, and bedding exchange;

· Communication and Visitation, including resident communications and visiting with others outside of the facility, which would also include parents of residents;

· Outcomes, including the identification of program outcomes and the annual evaluation of strengths and weaknesses according to the required performance indicators;

· Personnel Policies, including orientation and ongoing training;

· Maintenance Plan, including the reporting and correcting of safety hazards and unsanitary conditions; and

· Plan for Transfer Upon Closure, including who will maintain records if the entire organization closes

Fine: $200 ($200 per violation of health, safety or supervision)

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all terms of the Order of an Extended Conditional License are followed. Within 30 days receipt of this order, submit a policy and procedure manual that meets requirements to demonstrate compliance.

Statute Violated: Minnesota Statutes, section 245A.06, subdivisions 1 and 3.

2.  Other Licensing Violation

As a result of continued conditional license monitoring, a DHS licensor determined that the license holder has failed to comply with terms 1 and 3 of the Extended Conditional License dated October 21, 2024.

a. Term 1: The license holder submitted the documentation of the list of current clients and referral sources that were provided the approved extension of conditional license notice, as outlined in term 1, to DHS Licensing on May 8, 2025, when it was due by February 21, 2025; and

b. Term 3: The license holder failed to identify and include discrepancies found and corrective actions taken, as outlined in term 3, for each category reviewed in the self-monitoring reports submitted for the first quarter of 2025 that included the months of January, February, and March 2025.

Fine: $200 ($100 per each occurrence of a violation)

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all terms of the Order of an Extended Conditional License are followed.

Statute Violated: Minnesota Statutes, section 245A.06, subdivisions 1 and 3.

Repeat Violation: In a Correction Order that DHS issued on April 23, 2024, you were previously found in violation of this same statute.

Billing and Payment of the Fine

DHS will send you an invoice for the $400 fine. Payment must be made as directed on the invoice.

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

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

YOUR RIGHT TO APPEAL

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

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

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

Legal representation at the contested case hearing

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

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

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $200 fine for each health, safety, or supervision licensing violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

· DHS may impose a $100 fine for each occurrence of a licensing violation that is not related to health, safety, supervision, or maltreatment under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(v).

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

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

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

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

Questions

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

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

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

doc_type: Notice of Violation


report_date: October 21, 2024

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October 21, 2024

CERTIFIED MAIL

Jack Benson, Authorized Agent

On-Belay House

115 Forestview LN N

Plymouth, MN 55441

License Number: 800099

ORDER EXTENDING A CURRENT CONDITIONAL LICENSE

Dear Jack Benson:

The Department of Humans Services (DHS) is extending your license to provide Substance Use Disorder Children’s Residential Treatment services (CRF) at 115 Forestview LN N, Plymouth, MN 55441, on conditional status for one year, beginning January 31, 2025. This means you must meet certain conditions, detailed below, to maintain your license. On August 21-23, 2024, a full licensing review was completed. This order is based on your noncompliance with state and federal laws and rules governing the provision of licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR THE ORDER EXTENDING THE CONDITIONAL LICENSE

On January 31, 2023, the Commissioner of Human Services placed your license to provide chemical dependency services in a children’s residential facility on conditional status for two years. DHS conducted a modified licensing review of your facility on October 2, 2023, as a part of your conditional license status. Through continued monitoring, DHS issued a correction order on April 23, 2024, for not complying with terms of the Order of Conditional License. DHS conducted a full licensing review on August 21, 2024, and determined the license holder continues to have ongoing issues of non-compliance with required regulations and demonstrates a lack of consistent oversight of the program to ensure health and safety of the youth served. Due to the nature and severity of the violations found, which impact the health, rights, and safety of persons served in your care, the conditional status of your license is extended.

Nature and Severity:

o Failure to comply with background study requirements (violation numbered 1);

o Failure to follow the terms of the Order of Conditional License (violation numbered 2);

o Failure to ensure the whereabouts of each resident was known (violation numbered 3);

o Failure to ensure residents rights were protected (violation numbered 5);

o Failure to comply with health services requirements (violations numbered 4 and 9);

o Failure to comply with resident admission criteria requirements (violation numbered 6);

o Failure to comply with outcome measurement and program evaluation requirements (violation numbered 16);

o Failure to ensure maintenance was operated on a consistent and healthy basis (violation numbered 8);

o Failure to comply with discipline policy and procedure requirements (violation numbered 13);

o Failure to comply with maltreatment of vulnerable adults and minors reporting policies and procedures (violations numbered 10 and 11);

o Failure to comply with Individual Abuse Prevention Plan requirements (violation numbered 12);

o Failure to comply with staff orientation and annual training requirements (violations numbered 17 to 20);

o Failure to comply with resident treatment planning requirements (violation numbered 20); and

o Failure to comply with requirements for discharging and transitioning a resident (violations numbered 22 and 23).

Chronicity:

o One of the 30 violations are a repeat violation similar to the violation cited in the conditional license monitoring correction order dated April 23, 2024.

o Thirteen of the 30 violations are repeat violations similar to violations cited in the licensing review correction order dated December 4, 2023.

o 20 of the 30 violations are repeat violations similar to violations cited in the Order of Conditional License dated August 12, 2022.

o Eleven of the 30 violations are repeat violations similar to violations cited in the licensing review correction order June 16, 2020.

During the past 18 months when the license has been on conditional status, DHS Licensing has provided technical assistance and training to the license holder on multiple occasions regarding the applicable regulations and terms of the conditional status and the corrections ordered to meet compliance. Throughout this time, there have been multiple changes to the organization’s leadership structure. The changes have impacted the roles of the Program Director and the Compliance Officer, who are responsible for ensuring and monitoring the compliance of the applicable regulations. During the conditional status, the license has had three Program Directors, and the Compliance Officer has changed twice with the site-specific position having not yet been filled. Throughout the multiple leadership changes, the program has not been brought into compliance.

Licensing Violations

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

1. Violation: As a result of a licensing review, a DHS licensor determined that the license holder was not in compliance with background study requirements when the license holder allowed a staff person (SP2) to begin working in the children’s residential facility (license number 800099), regardless of whether or not the individual would have direct contact with persons served by the facility, under a set aside notice issued by the Background Studies Division for another licensed program of the license holder that is not licensed as a children’s residential facility (license number 800098). Set asides are issued for a specific licensed program. The license holder failed to initiate a background study for SP2 before an adult, regardless of whether or not the individual will have direct contact with persons served by the children’s residential facility, began working in the facility or setting resulting in the license holder’s failure to comply with the set aside notice for SP2.

SP2 was hired and began working in the children’s residential facility on December 19, 2023. At the time of the licensing review on August 21, 2024, the license holder had not submitted a background study request to DHS for SP2 for the children’s residential facility they were working in, license number 800099. However, a background study request had been submitted to DHS for SP2 for another licensed program, license number 800098, for which a set aside notice was issued on April 4, 2024, only allowing SP2 to work under license number 800098.

Statute Violated: Minnesota Statutes, sections 245C.04, subdivision 11 and 245C.22, subdivision 5.

Repeat Violation: The license holder was previously found in violation of this same statute in a Correction Order DHS issued on August 12, 2022.

2. Violation: The license holder failed to comply with term one and term five of the Conditional License dated August 12, 2022, in the following ways:

a. During a licensing review conducted on August 21, 2024, it was determined that the license holder failed to comply with term one. The conditional license status notice to be provided to the resident before they begin receiving treatment services was not maintained in the resident file as ordered; and

b. The license holder failed to meet term five in the following ways:

1) The license holder has submitted several quarterly and monthly self-monitoring results to DHS Licensing past the following required due dates:

a. November 15, 2023;

b. February 15, 2024;

c. March 1, 2024; and

d. September 20, 2024;

2) The results of the monthly reviews have not included discrepancies found and actions taken for each performance indicator in the self-monitoring plan. On February 16, 2024, DHS licensing met with the leadership of On-Belay House to discuss the self-monitoring plan and monthly reports not meeting requirements. Continued failure to comply with term five resulted in a correction order issued on April 23, 2024. In July of 2024, DHS Licensing provided the license holder with a standardized self-monitoring plan developed by DHS Licensing for the license holder to utilize. However, the monthly results submitted since that time have continued to not meet requirements; and

3) The licensing review on August 21, 2024, found discrepancies between the results in the monthly reports provided to DHS and what was reviewed during the licensing review. If the self-monitoring tool had been used as required, several compliance areas found to be in violation during the licensing review could have been corrected by the license holder prior to the review.

Statute Violated: Minnesota Statutes, section 245A.06, subdivision 3.

Repeat Violation: The license holder was previously found in violation of this same statute in a Correction Order DHS issued on April 23, 2024.

3. Violation: The license holder failed to know the whereabouts of each resident. On March 28, 2024, a resident was assigned to 15-minute safety checks, which required a staff person to visually check on the resident at least every 15 minutes. The resident absconded from the facility in the evening and their absence was unknown until the next morning; the staff did not complete the required safety checks.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 6.

4. Violation: The license holder failed to ensure the implementation of existing healthcare procedures and the development of appropriate healthcare policies and procedures to ensure ongoing healthcare monitoring of residents and the provision to timely access to healthcare services as well as meet the requirement for a medical professional’s involvement in the development of healthcare policies in the following ways:

a. The license holder’s Incident Report template contained a statement indicating the program Nurse must document the follow up taken for any medical related incident, however, the incident dates below did not include any documentation to demonstrate that any nursing follow up occurred:

1) July 8 and 14, 2024;

2) June 6, 2024;

3) March 14, 2024;

4) January 4 and 20, 2024;

5) December 3, 2023; and

6) November 15 and 19, 2023;

b. The license holder had several separate healthcare and medical policies that were duplicative and contradictory. The healthcare policies titled, Medical/Psychiatric Emergencies, Health Monitoring Plan, and Health and Hygiene Services do not clearly identify and describe how the program will ensure timely access to medical/healthcare services nor do they identify and describe current procedures used in practice as reported to DHS Licensors by the program’s nurse; and

c. The healthcare policies pertaining to the plan for the safe storage and delivery of medicine, Medication Administration, Medication Storage, and Medication Disposal, did not demonstrate that they were developed with the consultation of a medically licensed person. During the licensing review, the program’s medically licensed person was unable to describe the procedures identified in the policies and the procedures reported to be implemented in practice were either not consistent or described within the policies.

Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subpart 11, items A, B, and D.

5. Violation: The license holder failed to ensure resident rights were protected. Documentation and interviews with staff and residents indicated residents were required to “super clean” multiple areas of the building. There was no documentation to demonstrate this was therapeutic or consistent with resident’s treatment plans. Minnesota Statutes, section 144.651, subdivision 23, prohibits residents from performing labor or services for the facility unless those activities are included for therapeutic purposes and consistent with the residents’ treatment plan.

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

Repeat Violation: The license holder was previously found in violation of this same rule in a Correction Order DHS issued on December 4, 2023.

6. Violation: One of three resident files reviewed for requirements governing admission criteria (R3) did not contain documentation of the license holder’s determination before or at admission of whether:

a. The resident was a danger to themselves or others; and

b. The program was able to meet the resident’s cultural, emotional, educational, mental health, and physical needs.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

7. Violation: The license holder failed to have a written standing order protocol by a physician who is licensed under chapter 147, advanced practice registered nurse who is licensed under chapter 148, or physician assistant who is licensed under chapter 147A, to permit the license holder to maintain a supply of opiate antagonists on site.

Statute Violated: Minnesota Statutes, section 245A.242, subdivision 2.

8. Violation: The license holder failed to ensure that maintenance services were operated on a consistent basis to ensure the facility was kept in good repair. A DHS licensor observed broken ceiling tiles and a broken window. This was corrected on-site.

Rule Violated: Minnesota Rules, parts 2960.0110, subpart 3, item A and 2960.0200, item A.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

9. Violation: Three of four resident files reviewed for requirements governing health services did not meet requirements in the following ways:

a. The license holder did not maintain a record of illness reported by the resident, the action taken by the license holder, and the date of any medical, psychological, or dental care (R3);

b. The license holder did not complete medication verification upon admission for a resident who admitted with prescribed medications (R4);

c. The medication verification did not include the symptoms that the medication will alleviate and the symptoms that would warrant consultation with the physician (R2 and R3);

d. Documentation of the attempts to contact the child’s parent or guardian to seek permission for the facility to administer medications was not provided (R4);

e. The license holder did not document and follow the prescribing physician’s directions for monitoring medications used by the resident (R2 and R4);

f. The quantity of medications initially received from the pharmacy was not documented (R2 and R4); and

g. The medication administration record contained several blank entries in the month of May 2024. Therefore, the amount of medication given, dosage, time the medication was taken and whether a resident refused to take a prescription medication was unable to be determined for the prescribed medications on the medication administration record (R2).

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

Repeat Violation: The license holder was previously found in violation of this same rule in a Correction Order DHS issued on August 12, 2022.

10. Violation: The maltreatment of minors reporting policy and procedure did not meet requirements. The policy did not require the internal review to include an evaluation of whether there is a need for corrective action by the license holder to protect the health and safety of children in care.

Statute and Rule Violated: Minnesota Statues, 245A.66, subdivision 1, clause (1)

Repeat Violation: The license holder was previously found in violation of this same statute and rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

11. Violation: The license holder’s internal reviews of alleged or suspected maltreatment of minors did not meet requirements in the following ways:

a. The documentation for the report dated June 23, 2024, did not identify the date the review was completed; and

b.   There was no documentation of an internal review completed for the reports of alleged or suspected maltreatment made on November 14, 2023, and March 29, 2024.

Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1.

Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

12. Violation: Two of two resident files reviewed for requirements governing the individual abuse prevention plan (IAPP) did not meet requirements in the following ways:

a. An IAPP was not developed after the resident turned 18 years old, therefore the IAPP was not reviewed during each service plan review (R1);

b. The IAPP was not developed as part of the service initiation plan (R6); and

c. The IAPP did not contain an individualized assessment of the person's susceptibility to abuse by other individuals, including other vulnerable adults (R6).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivision 2, paragraph (b) and 245A.04, subdivision 2 and subdivision 11, paragraph (c).

Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on:

· August 12, 2022

· June 16, 2020

13. Violation: The license holder did not meet requirements governing the information that must be provided to residents at admission. The facility rules did not include the disciplinary consequences applied for modifying unacceptable behavior, and documentation did not demonstrate if the license holder communicated the facility rules and due process system verbally to the residents.

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 4, item B and 2960.0160, subpart 4, item A.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

14. Violation: The license holder failed to develop necessary staff drug and alcohol policies that describe a process for the disciplinary action, suspension, or dismissal of a staff person for violating the license holder’s drug and alcohol policy. The license holder has several policies referencing a staff person’s drug and alcohol use and staff misconduct. The policy, Drug and Alcohol Policy, Policy #209, states that the Personnel Drug Policy will be outlined and followed in section 24 of their Personnel Guidebook. However, section 24 does not identify a clear process for the actions the license holder will take for a staff person who violates their drug and alcohol policy. Section 24 also references a repealed Rule and its requirements, Minnesota Rule 9530.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a) and Minnesota Rules, part 2960.0470, subpart 4.

15. Violation: The license holder’s written program descriptions were inconsistent with the program being implemented. The program descriptions include services provided in another licensed program of the license holder and does not identify which services are applicable to the children’s residential facility.

Rule Violated: Minnesota Rules, part 2960.0180, subpart 2.

16. Violation: The license holder failed to meet the outcome measures, evaluations, and community advising requirements in the following ways:

a. The license holder did not complete an annual evaluation of the program’s strengths and weaknesses for calendar years 2022 and 2023 using the following performance indicators:

1) Accidents;

2) The use of restrictive procedures;

3) Grievances;

4) Adverse findings, allegations of maltreatment under Minnesota Statutes, section 626.556, citations and legal actions against the license holder;

5) Information from the programs outcomes and outcome measures;

6) Results of resident and family satisfaction surveys; and

7) Critical incidents; and

b. The license holder did not meet annually with the community leaders representing the area where the facility is located for calendar years 2022 and 2023.

Rule Violated: Minnesota Rules, part 2960.0060, subparts 3, item A and 6.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· August 12, 2022

· June 16, 2020

17. Violation: Two of six personnel files reviewed for requirements governing training did not meet requirements in the following ways:

a. The staff person was not trained to the specific mode of administration for the opiate antagonist used at the program (SP4); and

b. There was no documentation to demonstrate the staff person received training related to their duties in implementing the programs policies and procedures (SP4 and SP5).

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b) and 245A.242, subdivision 2.

18. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways (SP2, SP3, and SP5):

a. Documentation did not demonstrate the staff person received orientation to the following topics before having unsupervised contact with residents:

1) Culturally competent care;

2) Gender issues, including the psychosocial development of girls and boys;

3) Sexual orientation issues; and

4) Physical, mental, sensory, and health-related disabilities, bias, and discrimination); and

b. Documentation did not demonstrate that within 72 hours of first providing direct contact services, the staff person was oriented to the internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults receiving services.

Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0150, subpart 4, item C.

Repeat Violation: The license holder was previously found in violation of this same statute and rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

19. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways:

a.

a. Documentation did not demonstrate the staff person received ongoing training to:

1) Topics including meeting the needs of residents and skill development (SP1 and SP4);

2) Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572, annually (SP4);

3) The license holder’s program abuse prevention plan (PAPP), annually (SP4);

4) All internal policies and procedures related to the prevention and reporting of maltreatment of vulnerable adults receiving services, annually (SP1, SP4, and SP6);

5) The maltreatment of minors reporting requirements and definitions in chapter 260E, annually (SP4);

6) HIV Minimum Standards, annually (SP4 and SP6); and

7) At least 24 hours of in-service training for the annual year (SP1); and

b. Documentation did not include the date, number of hours, and the name of the entity/person(s) providing the training for each topic area (SP1, SP4, and SP6).

Statute and Rule Violated: Minnesota Statutes, sections 245A.66, subdivision 4, 245A.65, subdivision 3, and 245A.19, paragraph (a); and Minnesota Rules, parts 2960.0100, subparts 3, items A and B, and 5, and 2960.0150, subpart 4, item B.

Repeat Violation: The license holder was previously found in violation of this same statute and rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

20. Violation: Two of four personnel files reviewed for requirements governing the emergency plan did not meet requirements (SP4 and SP6). The license holder did not review the facilities emergency plan once at least every six months for calendar years 2023 and 2024.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

21. Violation: Two of two resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways:

a. The plan did not continually evolve based upon new information gathered about the resident’s condition (R2);

b. The objectives were not specific (R1 and R2);

c. The frequency of the intervention was not identified (R1 and R2); and

d. The minimum outcomes that were to be met before the resident is discharged were not included (R1 and R2).

Rule Violated: Minnesota Rules, parts 2960.0490, subparts 2 and 3, items C and E.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

· June 16, 2020

22. Violation: One resident file reviewed for requirements governing no eject discharges did not meet requirements (R4). Documentation did not demonstrate the following was completed before the license holder discharged a resident who had not yet reached their treatment plan goals:

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

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

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· August 12, 2022

· June 16, 2020

23. Violation: Two of three resident files reviewed governing discharge procedures, discharge documentation, and transition services plans did not meet requirements in the following ways:

a. There was no documentation to demonstrate the license holder returned all of the resident’s property to the resident upon discharge (R1 and R3);

b. There was no documentation of a written notice of the resident’s projected discharge date that was provided to the resident, their case manager, or their parents or legal guardian (R1);

c. Discharge documentation did not identify the extent to which the resident’s stay in the facility met the goals and objectives of the resident’s treatment plan (R1);

d. Discharge documentation did not identify which services, including education, were provided directly or indirectly to the resident and who provided the services (R1); and

e. The following elements of the transition services plan were not included (R1):

1) Budget plan and description of the resident’s financial and employment status; and

2) Treatment needs.

Rule Violated: Minnesota Rules, parts 2960.0090, subpart 3, and 2960.0190, subparts 1, items B and C, and 2, item A.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4. 2023

· August 12, 2022

24. Violation: Two of two resident files reviewed for requirements governing admission screenings did not meet requirements (R1 and R3). The screening instrument used did not include all components required by the gender-specific needs tool approved by the commissioner.

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

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

25. Violation: Two of three resident files reviewed for requirements governing the inventory of personal property did not meet requirements (R1 and R2). An inventory of personal property was not completed upon admission.

Rule Violated: Minnesota Rules, parts 2960.0070, subpart 4, and 2960.0090, subpart 3.

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

26. Violation: The license holder did not meet critical incident reporting requirements. The following incidents met the definition of a critical incident and were not submitted to DHS within 10 days of learning of the incident; they were submitted late:

a. An incident dated March 28, 2024, was submitted on May 10, 2024; and

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

Repeat Violation: The license holder was previously found in violation of this same rule in Correction Orders that DHS issued on:

· December 4, 2023

· August 12, 2022

27. Violation: Two of six personnel files reviewed for requirements governing qualifications did not meet requirements (SP2 and SP5). There was no documentation to demonstrate the staff person was trained in gender-based needs and issues.

Rule Violation: Minnesota Rules, part 2960.0100, subpart 6, item B.

28. Violation: The license holder did not maintain annual documentation of their efforts to contact and seek information from the cultural or racial community groups related to the resident’s cultural or racial minority backgrounds they serve to provide opportunities for the residents to associate with similar cultural and racial backgrounds for calendar year 2023.

Rule Violated: Minnesota Rules, part 2960.0100, subpart 2.

Repeat Violation: The license holder was previously found in violation of this same rule in a Correction Order that DHS issued on August 12, 2022.

29. Violation: The license holder’s satisfaction surveys did not contain an assessment of the following components:

a. The accuracy, usefulness, and appropriateness of the screening and assessment of the resident's physical and emotional well-being and functioning;

b. The positive and negative effects on the resident and the resident's family of the treatment offered to the resident, such as mental health, chemical dependency, or sex offender treatment; and

c. Support of family and community reintegration, if appropriate.

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

Repeat Violation: The license holder was previously found in violation of this same rule in a Correction Order that DHS issued on August 12, 2022.

30. Violation: The license holders plan for transfer of clients and records upon closure did not meet requirements in the following ways:

a. The plan for transfer of clients and records upon closure did not include a signature or other documentation demonstrating the agreement; and

b. A controlling individual did not sign that the plan for transfer of clients and records upon closure was annually reviewed for calendar year 2023.

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

Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on:

· August 12, 2022

· June 16, 2020

License holders determined to have a background study violation are required to pay a $200 fine for each violation. Because an extension of a Conditional License is a more severe sanction against your license, DHS is not imposing this fine.

Immediate corrective action required

You must immediately correct the violations cited above. If you fail to demonstrate substantial compliance with licensed children's group residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, parts 2960.0430 through 2960.0490, requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license.

CONDITIONAL LICENSING TERMS

In addition to the children’s residential facilities and chemical dependency services licensing rules and statutes, you are required to comply with the following terms:

1. Revised Condition: Within 14 days receipt of this order, you must notify current clients and all parties who refer clients to the program of the extension of the conditional status of the license. The notification must be approved by DHS Licensing prior to being sent and must specify the length of time of the extension of the conditional status of your license, the reasons for the extension of the conditional license, and it must include either a copy of the Order Extending the Conditional License or an offer to provide a copy of the order upon request, therefore, within 7 days receipt of this order, you must contact DHS Licensing to assist you with the development and approval of a revised conditional license notice.

While the license is on conditional status, you must notify new residents and referral sources the license is on conditional status before they begin receiving services. The notification must consist of the notice approved by DHS Licensing, identified above. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file. Within 30 days receipt of this order, you must submit, to DHS Licensing, a list of all current clients and referral sources that received the notice.

2. Revised Condition: Within 14 days of receipt of this order, you must submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Program Director, ADC, ADC Supervisor, or any other position providing direct care services. The Compliance Officer must allocate 75 percent of their working hours to the duties of Compliance Officer at license number 800099. The license holder must submit a revised change of licensing information form to identify the compliance officer. The License holder must notify DHS licensing within 5 business days if there is any change in the appointment of the Compliance Officer. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor:

a. 2 years of professional experience in the following:

1) A regulatory or compliance position; and

2) Involved in direct care as a substance use technician or counselor; or

3) If applicable, the development and implementation of mental health or substance use disorder treatment planning in a DHS licensed Children’s Residential Facility under Minnesota Rules, Chapter 2960;

b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and Minnesota Rules, Chapter 2960, Children’s Residential Facilities; and

c. A Bachelor’s degree or higher in Human Services, Social Work, Sociology, Psychology; or, a related field may substitute for one year of professional experience in Human Services, Social Work, Sociology, Psychology or a related field.

3. Revised Condition: Within 30 days of the receipt of this order, you must implement the DHS Licensing self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct within the first quarter a review of the License Holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapter 245A and Minnesota Rules, Chapter 2960. This includes an assessment of staff implementing the policies and procedures.

Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan. Discrepancies found within the reviews and corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 1 year from the effective date of the conditional license or otherwise determined by DHS licensing.

4. New Condition: Within 60 days from when you receive this order, you must submit a fully revised and compliant policy and procedure manual to DHS for review and approval. The policy and procedure manual must include all of the necessary policies and procedures the license holder requires to maintain compliance with the licensing requirements under Minnesota Statutes and Minnesota Rules. The policy and procedure manual must explicitly identify the policies and procedures applicable to the licensing requirements that govern the children’s residential facility license.

Within 45 days from the approval from DHS Licensing, the license holder must train all program staff to their duties in implementing the program’s policies and procedures and submit a training record to DHS Licensing demonstrating the completion of the training.

Please submit documentation via the following methods:

1. By secure email to: tina.christensen@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services
ATTN: Tina Christensen
Licensing Division
PO Box 64242
St. Paul, MN 55164-0242

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

· Clearly state that you are requesting reconsideration of the conditional license

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

· Supply information that is accurate or more complete

· State why you believe your license should not be on a conditional status

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 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

Licensing Division

Attention: Legal Unit

PO Box 64242

St. Paul, MN 55164-0242

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Licensing Division

Attention: Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Conditional license stayed pending reconsideration

If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all applicable laws and rules, including Minnesota Rules, Chapter 2960, which includes children's group residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, parts 2960.0430 through 2960.0490.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.06, subdivision 1.

· Children’s Residential Facilities with Chemical Dependency services are required to follow Minnesota licensed children's group residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, parts 2960.0430 through 2960.0490,

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4.

· If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4.

· Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order.

Questions

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

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

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