raw_content:
March 14, 2024

Carmeann Foster, Authorized Agent

Rebound Inc

710 W Broadway Ave N

Minneapolis, MN 55411

License Number: 1090428 (CRF)

Investigation Number: 202400317

CORRECTION ORDER

Dear Carmeann Foster,

A licensing investigation of Naima House, located at 1017 Humboldt Ave N, Minneapolis, MN 55411 was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120; children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220; and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. As a result of this licensing investigation a Correction Order is being issued.

A. Reason for Correction Order

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

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

Practices

1. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A.

Violation: The license holder’s practice for reporting critical incident reports did not meet requirements. The license holder did not submit a critical incident report within 10 days for incident dated November 30, 2023 for a client who absconded and did not return to the program within 24 hours.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the practice for critical incident reports meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in Correction Orders dated:

· November 22, 2021; and

· April 28, 2023

2. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b).

Violation: The license holder did not monitor the implementation of their resident supervision policy. A staff member did not conduct hourly wellness checks of residents on November 30, 2023 as stated in the license holder’s policy. As a result, a resident absconded from the program and was gone for several hours before staff were aware.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must monitor the implementation of their policies.

Client File

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

Violation: One resident file was reviewed for requirements governing no eject (R1) and did not meet requirements. The file did not contain documentation of the following:

a. License holder conferred with other interested persons to review the issues involved in the decision;

b. Whether additional strategies to resolve the issues leading to the discharge could have been developed to allow the resident an opportunity to continue to receive services; and

c. The reasons for discharge and the alternatives considered or attempted when the decision to discharge was warranted.

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

Repeat Violation: The license holder was cited for a similar violation in Correction Orders dated:

· November 22, 2021; and

· April 28, 2023

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

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

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


state: MN

facility_name: Naima House

raw_content:
April 28, 2023

Carmeann Foster, Authorized Agent

Rebound Inc.

710 W Broadway Ave N

Minneapolis, MN 55411

License Number: 1090428

CORRECTION ORDER

Dear Carmeann Foster:

On January 23 through 26, 2023, a licensing review and licensing investigation of Naima House, located at 1017 Humboldt Avenue North, Minneapolis, MN 55411, was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, and residential shelter services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

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

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

Postings and Physical Plant

1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, and Minnesota Rules, part 2960.0050, subpart 3, item D.

Violation: The license holder failed to ensure postings met requirements in the following ways:

a. The license holder maintained a posting of an outdated program abuse prevention plan (PAPP); and

b. A copy of the resident’s rights was not posted in the staff work-station.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all postings for vulnerable adult maltreatment meets all applicable requirements.

2. Citation: Minnesota Rules, parts 2960.0050, subpart 1, item H, and 2960.0110, subpart 3, item A.

Violation: The license holder did not ensure the resident’s right to live in clean and safe surroundings was protected by ensuring that housekeeping was maintained on a consistent, healthy basis. A DHS Licensor observed cleanliness issues in a resident bathroom and in the kitchen.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the residents right to live in clean surroundings is protected.

Policies and Practices

3. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) and Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: The license holder failed to monitor the implementation of their plan for the safe storage and delivery of medicine with the program’s medically licensed person in the following ways:

a. Documentation did not demonstrate that a medically licensed person provided consultation and review of the administration of medications at least monthly for the months of August, September, October, and November 2022;

b. Staff persons responsible for the administration of medications to residents were not provided program specific medication assistance training by the program’s registered nurse;

c. Documentation to demonstrate whether medications were packed for home visits or when the resident was away from the facility was inconsistent with the plan; and

d. The process for obtaining and documenting the need for medication refills was not followed as described in the plan. As a result, resident medication was not administered as directed by the prescriber.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their health services policies and procedures meets all applicable requirements. Within 60 days receipt of this order, submit documentation demonstrating the plan for the safe storage and delivery of medicine was reviewed and approved by the program’s current medically licensed professional to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021

4. Citation: Minnesota Statutes 245A.04, subdivision 9 and Minnesota Rules, part 2960.0170, subpart 1.

Violation: The license holder failed to meet the conditions of an approved Variance, dated October 6, 2022 through January 15, 2023. DHS Licensing was not notified within 24 hours of significant problems or safety concerns involving the resident named in the variance (resident file numbered 1).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of variance conditions are followed.

5. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A.

Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not include the following required performance indicators:

a. Accidents;

b. The use of restrictive procedures;

c. Grievances;

d. Results from resident and family satisfaction surveys; and

e. Critical incidents

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021

6. Citation: Minnesota Statues, sections 245A.04, subdivisions 9 and 14, paragraph (b), and Minnesota Rules, part 2960.0080, subparts 6 and 17, item A.

Violation: The license holder failed to meet requirements governing critical incidents in the following ways:

a. Critical incident reports were not submitted to DHS for five incidents (October 17, November 9 and 27, 2022, and January 9 and 11, 2023)

b. The license holder’s Critical Incident Reporting and Review policy did not define critical incidents according to DHS’s definitions and criteria; and

c. The license holder failed to monitor the implementation of their Critical Incident Reporting and Review and Abscond policies in the following ways:

1. Incidents were not documented on the forms nor maintained in the resident’s record as described in the Critical Incident Reporting and Review policy;

2. Incident report documentation did not include all required components identified in the Critical Incident Reporting and Review policy; and

3. The notifications to a resident’s referring agent for when a resident ran from the program were not documented in case notes as indicated in the Abscond policy.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the implementation and monitoring of their incident reporting policies and procedures meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

Personnel Files

7. Citation: Minnesota Statutes, section 245A.041, subdivision 5.

Violation: Two of two personnel files reviewed for requirements governing documentation requirements (personnel files numbered 1 and 2) did not meet requirements. The license holder failed to document the first date the staff person began working in a facility or setting.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements.

8. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0100, subparts 3, item A, and 5.

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

a. The staff person was not oriented to general and special needs, including disability needs of families served;

b. The staff person was not oriented within 72 hours of first providing direct contact services to the program abuse prevention plan (PAPP); and

c. Documentation of orientation did not meet requirements in the following ways:

1. Documentation did not identify the number of hours and the name of the entity that provided the training in each topic area; and

2. Documentation did not accurately identify the date training was completed; documentation identified that the medication administration training had been completed, but DHS licensors were informed that the staff person had yet to complete the training.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

9. Citation: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subpart 5.

Violation: One personnel file reviewed for requirements governing ongoing training (personnel file numbered 2) did not meet requirements in the following ways:

a. There was no documentation to demonstrate the following:

1. The staff person received annual training in vulnerable adults maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572;

2. The staff person received annual training on the program abuse prevention plan (PAPP) for the year 2022;

3. The staff person received annul training on the programs internal policies and procedures related to the prevention and reporting of maltreatment for the year 2022; and

4. The staff person reviewed the emergency plan at least once every 6 months for calendar year 2022; and

a. The annual training documentation did not demonstrate the date, number of hours, and the name of the entity that provided the training in each topic area.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

Resident Files

Resident files reviewed are identified in the following manner:

· Shelter Care Services: Resident files numbered 1

· Group Residential Services: Resident files numbered 2 and 3

10. Citation: Minnesota Rules, part 2960.0070, subpart 3, items B.

Violation: Two of two resident files reviewed for requirements governing resident information (resident files numbered 1 and 2) did not meet requirements. The resident file did not include the following required information:

a. Time of admission;

a. Circumstances leading to admission;

b. Spiritual or religious affiliation of the resident’s family; and

c. Attempts to obtain the placing agency’s case plan goals.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

11. Citation: Minnesota Rules, parts 2960.0050, subpart 3, items A and B, 2960.0080, subpart 4, and 2960.0160, subparts 2, item C, and 4, item B.

Violation: Two of two resident files reviewed for requirements governing admission criteria and procedures did not meet requirements. The file did not contain documentation to demonstrate:

Whether the license holder was able to meet the resident’s cultural, emotional, educational, mental health and physical health needs (resident files numbered 1 and 2);

a. The facility rules and due process for residents was explained verbally and provided in writing to the resident (resident files numbered 1 and 2);

b. Within 24 hours of admission:

1. A written copy of the resident’s basic rights was explained verbally and provided to the resident (resident files numbered 1 and 2);

2. The resident’s parent, guardian, or custodian was informed within a reasonable time after admission that information on the resident’s basic rights is available (resident file numbered 2); and

3. A copy with the description of applicable programs and activities available was provided to the resident (resident file numbered 2).

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

12. Citation: Minnesota Rules, parts 2960.0070, subpart 4 and 2960.0090, subpart 3.

Violation: Two of two resident files reviewed for requirements governing the inventory and handling of resident property did not meet the requirements in the following ways:

a. The resident’s property was not inventoried upon admission (resident files numbered 1 and 2); and

b. The files did not include a signed receipt demonstrating the license holder returned all of the residents’ personal property (resident file numbered 1).

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

13. Citation: Minnesota Statutes, section 245A.65, subdivisions 1, paragraphs (c) and 2, (a) and (b), and 626.557, subdivision 14, paragraph (c).

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

a. There was no documentation to demonstrate that a resident who turned 18 received orientation to the required policies and procedures governing the maltreatment of vulnerable adults for the following:

1.   The internal and external reporting policies, including the telephone number for MAARC; and

2.   The program abuse prevention plan; and

b. An IAPP was not developed.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the vulnerable adults orientation and development of an IAPP meets all applicable requirements.

14. Citation: Minnesota Rules, part 2960.0520, subparts 2, items A and B, and 3.

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

a. A health screening was not arranged for within 24 hours of admission;

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

c. An immediate needs plan was not developed.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

15. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A through D.

Violation: One resident file reviewed for requirements governing admission screenings (resident file numbered 2) did not meet requirements in the following ways:

a. The file did not contain documentation to demonstrate that the license holder completed the following screens:

1. Mental health;

2. Substance use disorder; and

3. The degree to which the family desires to be involved; and

a. The following screens did not contain a date to determine if they were started within 3 working days and completed within 6 working days:

1. Health;

2. Education;

3. Sexually abusive behavior; and

4. Vulnerability assessment.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

16. Citation: Minnesota Rules, part 2960.0070, subpart 5, item E.

Violation: One of two resident files reviewed for requirements governing program services (resident file numbered 2) did not meet requirements. The license holder did not demonstrate that they contacted the resident’s case manager to ensure substance use disorder services were provided to a resident whose screening indicated a high risk for substance abuse and a recent substance use disorder assessment indicated a need for services.

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

17. Citation: Minnesota Rules, part 2960.0180, subpart 2, item B.

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

a. The license holder failed to develop a treatment plan (resident file numbered 2); and

b. The license holder failed to review the treatment plan on a monthly basis for October 2022 (resident file numbered 2).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plan and service plan reviews meets all applicable requirements.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

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

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

a. There was no documentation to demonstrate the license holder contacted the resident’s prescribing medically licensed person to verify information regarding their prescription medication (resident file numbered 1 and 2);

b. There was no documentation to demonstrate the license holder followed the prescribing physician’s directions for monitoring medications used by the resident (resident file numbered 1 and 2);

c. There was no documentation to demonstrate the license holder recorded the administration of medications for a resident prescribed medication (resident file numbered 1); and

d. The medication administration record for the sampled months of September and October 2022 did not include the amount of medication given. Documentation did not identify whether the resident received the medication on the following dates (resident file numbered 2):

1. September 1, 3-11, 13-17, and 19-30, 2022; and

2. October 3-5, 7-8, 10-15, 17-31, 2022.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

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

Violation: One resident file reviewed for requirements governing a no-eject discharge (resident file numbered 2) did not meet requirements. The file did not contain documentation to demonstrate the following:

a. If any additional strategies to resolve the issues leading to discharge could have been developed to allow the resident opportunity to continue receiving services; and

b. The reasons for discharge and the alternatives considered or attempted when the decision to discharge were warranted.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

20. Citation: Minnesota Rules, parts 2960.0190, subparts 1, items A, and 2, items A and B; and 2960.0520, subpart 2, item C.

Violation: Two of two resident files reviewed for requirements governing discharge procedures, documentation, and the transition services plan did not meet requirements in the following ways:

a. The file did not include documentation of the name and address of the party the resident was released to following discharge (resident file numbered 1);

b. A transition services plan was not developed (resident file numbered 1); and

c. The discharge documentation did not include the following required components (resident files numbered 1 and 2):

1. The extent to which the resident’s stay in the program met the goals and objectives of their treatment plan; and

2. Identification of services that were recommended but were not provided to the resident.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 22, 2021.

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

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

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

2. By mail:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact Tina Christensen, Human Services Licensor at 651-431-6610.

Tina Christensen, Human Services Senior Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


facility_name: Newport Academy

raw_content:
August 19, 2025

Keith Thompson, Controlling Individual

Minnesota Health Operations

3990 Hillsboro Pike, STE 330

Nashville, TN 37215

License Number: 1108472 (CRF)

CORRECTION ORDER

Dear Keith Thompson:

On June 2, 2025, the Department of Human Services (DHS) received information that a change to the authorized agent position occurred. As a result, DHS has determined the license holder to be in violation of statute requirements. DHS is issuing this order which requires you to take the corrective action as described below under the violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATION

DHS determined that your program did not follow the following statute, as described below.

Violation: The license holder did not notify the commissioner by the tenth business day after a change to the Authorized Agent was made, nor did the license holder provide additional information requested by the commissioner. On June 2, 2025, DHS was informed that the license holder’s delegated Authorized Agent needed to be updated. DHS contacted the license holder on June 11, 2025, and August 4, 6, and 13, 2025, to provide instructions and the appropriate forms to complete the change, however, the license holder has yet to provide DHS with the required forms and information that has been requested to complete the change.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (b).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the notification required for a change to a license meets all applicable requirements. Within 7 days of receipt of this order, submit the required forms and information requested to the assigned Licensor to demonstrate compliance.

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order in writing. Your request must:

1. Specify the parts of the correction order that are alleged to be in error;

2. Explain why they are in error; and

3. Include documentation to support the allegation of error.

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Legal authority for this licensing action

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

· The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

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

Sincerely,

Tina Christensen, Lead Licensor

Licensing Division

Office of Inspector General

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


raw_content:
March 3, 2025

Annie Gendaszek, Authorized Agent

Minnesota Health Operations

3990 Hillsboro Pike Suite 330

Nashville, TN 37215

License Number: 1108472 (CRF)

Report Number: 202310733

AMENDED CORRECTION ORDER

NOTICE: This Amended Correction Order supersedes a Correction Order issued December 2, 2024, which must be destroyed. The Department of Human Services, Division of Licensing (“DHS”) received your request for reconsideration of the Correction Order on December 23,2024. This Amended Order reflects the final decision on the request for reconsideration issued on February 6, 2025.

Dear Annie:

On September 9, 10, 11, and 12, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Newport Academy, located at 1726 7th Avenue S, Saint Cloud, MN 56301. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential services under Minnesota Rules, part 2960.0010 through 2960.0120, children’s group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, adolescent residential chemical dependency treatment under Minnesota Rules, part 2960.0430 through 2960.0490, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, and restrictive techniques under Minnesota Rules, part 2960.0710. As a result, DHS is issuing this order which requires you to take the corrective actions as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Policies and Procedures

1. Violation: The license holder’s Emergency Plan, 7.2 Emergency Response Plan, did not meet requirements in the following ways:

a. The plan’s procedure for responding to the disappearance of a resident required the use of a staff notification system and for other staff persons to respond. The procedure did not describe what actions staff should take if other staff could not respond and it did not describe what the staff notification system consisted of;

b. The plan did not identify actions the staff must take for other emergency situations that may require a law enforcement or other emergency response; and

c. The plan did not include the “Crisis Response Code Call Protocol,” a practice identified in an internal review completed on April 1, 2024.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their emergency plan meets all applicable requirements. Within 30 days receipt of this order, submit a revised emergency plan that demonstrates compliance.

2. Violation: The license holder’s admission policy did not meet the requirements for rules governing adolescent resident chemical dependency treatment. The admission policy did not include a protocol for addressing the needs of individuals in need of emergency medical care not provided by the program and individuals who pose a substantial likelihood of harm to themselves or others if the behavior is beyond the behavior management capabilities of the program and staff, or that all denials of admission that involve the commission of a crime against a license holder’s property must be reported to a law enforcement agency.

Rule Violated: Minnesota Rules, part 2960.0480, subparts 1 and 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their admission policies meet all applicable requirements. Within 30 days receipt of this order, submit a revised policy that demonstrates compliance.

3. Violation: The license holder’s program abuse prevention plan did not meet requirements. The assessment of the physical plant did not include:

a. An assessment of the physical plant that includes fire escapes and outer buildings; and

b. An assessment of the environment that includes the location of the program in a particular neighborhood or community and the type of grounds and terrain surrounding the building. The assessment did not include the “look-out.”

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their program abuse prevention plan that meets all applicable requirements. Within 30 days receipt of this order, submit a program abuse prevention plan that addresses all requirements.

4. Violation: The license holder’s facility rules did not include the following:

a. All consequences that will be applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior, including behaviors that might warrant 1:1 supervision; and

b. The circumstances that will result in the use of restrictive procedures are not included in the rules provides to the residents.

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 4, items A, B, and C.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that their facility rules meet all requirements. Within 30 days receipt of this order, submit revised rules that demonstrate compliance.

Practices

5. Violation: The license holder did not monitor the implementation of their policies and procedures. The program abuse prevention plan stated the program would be staffed with 1 staff for every 6 residents. Documentation indicated this ratio was not maintained in practice.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the implementation of policies and procedures is monitored.

6. Violation: The license holder did not ensure the residents’ rights according to Minnesota Statutes, section 144.651, subdivision 23, were protected. Residents were responsible for performing labor for the facility without the labor being therapeutic or appropriately goal related.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure residents are not performing labor or services for the facility aside from labor performed for therapeutic purposes as outlined in the individual resident’s treatment plan.

7. Violation: The license holder’s admission process did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the license holder determined the following conditions were met before allowing a resident to admit to the license holder’s program:

i. The resident was screened by a mental health professional using a process equivalent to the required process identified in Minnesota Statutes, section 245.4885;

ii. The developmental and mental health needs of the resident could be met by the program; and

iii. The resident met the admission criteria in the license holder’s admission policy; and

b. The admission process allowed for the admission authority to come from various individuals who were not directly involved with the program itself, rather the program’s organization.

Furthermore, the admission process did not include the program’s direct involvement to assess the current capacity of the program, including the staff and other residents, to determine whether the program could meet the resident’s needs.

Rule Violated: Minnesota Rules, parts 2960.0160, subpart 2, items B, C, and F, 2960.0480, subpart 1, and 2960.0670, subpart 2, items C and F.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission processes meet all applicable requirements. Within 30 days receipt of this order, the license holder must submit documentation demonstrating how the program determines and documents the requirements in item A and must submit a revised admission policy that meets all applicable requirements.

8. Violation: The license holder did not have documentation to demonstrate that they met the requirements governing outcome evaluations:

a. The license holder did not have documentation demonstrating that they annually evaluated the program’s strengths and weaknesses for the year of 2022, and the evaluation for 2023 was missing the following performance indicators:

i. Accidents;

ii. The use of restrictive procedures;

iii. Grievances;

iv. Adverse findings and allegations of maltreatment;

v. Outcomes and outcome measures; and

vi. Critical incidents;

b. The license holder did not have documentation that they used the program evaluations reports and findings as a basis to make improvements in its programs; and

c. The license holder’s 2022 and 2023 documentation of annual meetings with area community leaders did not demonstrate that they advised community leaders on the nature of their program, the types of residents served, and the results of the services provided to the residents.

Rule Violated: Minnesota Rules, part 2960.0060, subparts 3, item A, 4, and 6.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their outcome evaluations meet all applicable requirements. Within 30 days receipt of this order, submit the program evaluation for the annual year 2024.

9. Violation: The license holder’s documentation of their reviews of the use of restrictive procedures did not meet requirements in the following ways:

a. The quarterly reviews for 2022 Quarter 4 and 2023 Quarter 1 were not completed;

b. The quarterly reviews completed for 2023 and 2024 did not consider:

i. Any patterns or problems indicated by similarities in the time of day, day of the week, duration of use, individuals involved (exclusive of 2024 Quarter 2), or other factors associated with the use of restrictive procedures; and

ii. Any staff injuries resulting from the use of restrictive procedures; and

c. The annual written review of the use of restrictive procedures was not completed for the year 2022 and did not address the entire year’s data for 2023.

Rule Violated: Minnesota Rules, part 2960.0710, subparts 2, item D, and 11, items A and B.

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

10. Violation: The license holder’s staffing plan did not identify the assignments of all facility staff.

Rule Violated: Minnesota Rules, part 2960.0100, subparts 1, items A, B, and C, and 2960.0470, subpart 3.

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

11. Violation: The license holder did not have documentation to demonstrate that a mental health professional provided weekly face-to-face clinical supervision to all staff providing program services to clients for the weeks beginning March 24, 2024, and September 1, 2024. For the week beginning March 24, 2024, 14 staff did not attend clinical supervision, and for the week beginning September 1, 2024, 25 staff did not attend.

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

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

12. Violation: The license holder did not follow requirements governing grievances for grievances filed in the years of 2023 and 2024. A total of 11 grievances were reviewed for the year 2023, and 21 for 2024:

a. A person filing a grievance did not receive a response within five days for 8 grievances received in 2023 and 1 in 2024; and

b. The license holder did not document investigation findings and resulting actions taken by the license holder for 15 grievances received in 2024.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, items A and B.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their grievances meet all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating all staff have been re-trained on the grievance procedure.

13. Violation: The license holder did not meet all requirements governing satisfaction surveys. The satisfaction surveys did not include gathering feedback on the positive and negative effects on the resident and the resident’s family of the treatment offered to the resident.

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

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same statute and rule.

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

Personnel

14. Violation: One personnel file reviewed for rules governing alcohol and drug counselor staff qualifications did not meet requirements. The license holder’s personnel file did not include documentation of the staff person’s qualifications to provide adolescent treatment services (personnel file numbered 6).

Rule Violated: Minnesota Rules, part 2960.0460, subpart 5, items B and C.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure personnel files meet all applicable requirements. This was corrected on site during the course of the licensing review.

15. Violation: Eight of nine personnel files reviewed for rules governing orientation training did not meet requirements in the following ways:

a. The license holder did not ensure that staff who have direct contact with residents attend and successfully complete orientation training before having unsupervised contact with residents that included:

i. Emergency procedures including evacuation routes, emergency telephone numbers, severe storm and tornado procedures (personnel file numbered 10);

ii. Maltreatment of minors reporting requirements under Minnesota Statutes, sections 260E (personnel files numbered 8 and 10);

iii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 8 and 10);

iv. General and special needs, including disability needs, of residents and families served (personnel files numbered 1, 2, 3, 6, 8, and 10);

v. Operational policies and procedures (personnel file numbered 10); and

vi. Data practice regulations and issues (personnel files numbered 8 and 10).

b. The license holder did not have documentation to support that the following orientations and trainings were provided to staff and volunteers:

i. Culturally competent care (personnel file numbered 10);

ii. Racial bias and racism issues (personnel file numbered 10);

iii. Gender issues, including the psychosocial development of boys and girls (personnel file numbered 10);

iv. Sexual orientation (personnel file numbered 10); and

v. Physical, mental, sensory, and health related disabilities, bias, and discrimination (personnel file numbered 10).

c. The license holder did not ensure that a staff person completed trainings on restrictive procedures that included the following topics before the use of a restrictive procedure:

i. Documentation standards for the use of restrictive procedures (personnel files numbered 1, 2, 3, 6, 8, and 12);

ii. Time limits of restrictive procedures (personnel files numbered 1, 2, 3, 6, 8, and 12); and

iii. Obtaining approval for the use of restrictive procedures (personnel files numbered 1, 2, 3, 6, 8 and 12).

d. The license holder did not have documentation to demonstrate the staff person was trained on the program’s drug and alcohol policy (personnel file numbered 10);

e. The license holder did not ensure that staff received orientation to the following topics within 72 hours of providing direct contact services to a vulnerable adult (personnel file numbered 10):

i. Vulnerable adults maltreatment reporting requirements and definitions in sections 626.557 and 626.5572;

ii. The program abuse prevention plan; and

iii. All internal reporting policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

f. The license holder did not provide orientation training to staff on HIV minimum standards within 72 hours of employment (personnel; files numbered 3, 6, and 10);

g. The license holder did not have documentation of the following trainings completed during the first 45 days of employment and before assuming sole responsibility for the care of residents for staff members who provided mental health program services:

i. Psychiatric emergencies and crisis services (personnel file numbered 12); and

ii. Problems and needs of residents with severe emotional disturbances and families (personnel files numbered 3 and 6).

h. The personnel file of an overnight staff member did not include documentation of crisis intervention strategies that included the license holder’s restrictive procedures protocols (personnel file numbered 13).

Statute and Rule Violated: Minnesota Statutes, sections 245A. 19, paragraph (b), 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0010, subpart 3, item A, 2960.0150, subpart 4, item C, 2960.0710, subparts 2, item C, and 9, items B, C, D, and E, and 2960.0650, subpart 1, items A, B, D, E, F, and G.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same statute and rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their orientation training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating that personnel file numbered 10 has received training on maltreatment of minors and vulnerable adults maltreatment reporting.

16. Violation: Six of twelve personnel files reviewed for requirements governing staff training did not meet requirements. The license holder did not have documentation to demonstrate that they:

a. Required staff to undergo training in the specific mode of administration of emergency overdose treatment used at the program which may include intranasal administration, intramuscular injection, or both (personnel file numbered 3); and

b. Provided training to program staff related to their duties in implementing the program’s policies and procedures necessary to maintain compliance with licensing requirements under Minnesota Statutes and Minnesota Rules. The “shadow checklist” was not completed (personnel files numbered 1, 6, 7, 11, and 12).

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

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

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

a. The license holder did not have documentation of staff receiving the following trainings annually:

i. Vulnerable adults maltreatment reporting requirements and definitions in sections 626.557 and 626.5572 (personnel files numbered 4, 5, 7, and 11);

ii. The program abuse prevention plan (personnel files numbered 4, 5, 7, and 11);

iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 4);

iv. The maltreatment reporting requirements and definitions in chapter 260E (personnel files numbered 4, 5, 7, and 11); and

v. HIV minimum standards (personnel files numbered 4, 5, and 11); and

b. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 4, 5, 7, and 11).

Statute and Rule Violated: Minnesota Statutes, sections 245A.19 paragraph (b), 245A.65, subdivision 3, 245A.66, subdivision 4, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subpart 3, item A.

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

18. Violation: Seven of twelve personnel files reviewed for rules governing individual staff development and evaluation plans did not meet requirements. The license holder did not ensure that an annual individual staff development and evaluation plan was developed and implemented (personnel file numbered 10), and the plan was not developed within 90 days after the staff person began employment and at least annually thereafter (personnel files numbered 3, 4, 7, 9, 12, and 13).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their individual staff development and evaluation plans meet all applicable requirements.

Residents

19. Violation: Four of four resident files reviewed for rules governing resident information did not meet requirements. The licensor holder did not document in the resident’s file the resident’s tribal affiliation (resident files numbered 1, 2, 4, and 5) or a description of strengths and assets of the resident (resident files numbered 4 and 5).

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

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

20. Violation: Eleven of eleven resident files reviewed for rules governing admission criteria did not meet requirements. Before or at the admission of a resident, the license holder did not document whether the resident is a danger to the resident’s self or others, whether the program is able to meet the resident’s cultural emotional, educational, mental health, or physical needs (resident files numbered 1 through 5 and 8 through 13).

Rule Violated: Minnesota Rules, parts 2960.0160, subpart 2, items A and C, 2960.0480, subpart 1, and 2960.0670, subpart 2, item F.

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

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

a. The license holder did not inventory a resident’s personal property upon admission (resident file numbered 5) or the inventory was not signed by the resident or staff member (resident file numbered 4);

b. The license holder did not tell the resident’s parent, guardian, or custodian within a reasonable time after admission that information on the resident’s rights was available (resident files numbered 2 and 4);

c. Facility appeal procedures were not made available to a resident at the time of admission (resident files numbered 1 through 4); and

d. Residents receiving substance use treatment did not receive orientation to the HIV minimum standards and that educational information concerning treatment options of opioid addiction was provided (resident files numbered 1 and 4).

Statute and Rule Violated: Minnesota Statutes, section 245A.19, paragraph (b), and Minnesota Rules, parts 2960.0050, subpart 3, item B and 2960.0160, subpart 4, item A.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same statute and rule.

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

22. Violation: Two of two resident files reviewed for rules governing vulnerable adult orientation did not meet requirements. There was no documentation that a new adult receiving services from the program received orientation to the internal and external reporting polices regarding maltreatment of vulnerable adults and the program abuse prevention plan (resident files numbered 5 and 7) or that the license holder sought consent to the discloser of suspected maltreatment from the resident, a guardian, conservator, or legal representative (resident file numbered 7).

Statute Violated: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (c) and 2, paragraph (a).

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

23. Violation: Five of six resident files reviewed for rules governing the initial services plan of a resident receiving substance use treatment did not meet all requirements. The initial services plan did not address any immediate health and safety concerns (resident files numbered 1, 9 , 11, 12, and 13), suggestions for the client during the team between their intake and first treatment session (resident file numbered 1), or what issues are to be addressed in the first treatment sessions (residents files numbered 1, 9, and 11).

Rule Violated: Minnesota Rules, part 2960.0485.

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

24. Violation: Four of four resident files reviewed for rules governing admission screenings did not meet requirements in the following ways:

a. The health screening was not completed within 24 hours of admission (resident files numbered 1, 2, and 4);

b. The substance use disorder screening was not completed within six days of admission (resident files numbered 2 and 5);

c. The screening for sexually abusive behavior was not completed within six days of admission (resident file numbered 5);

d. The vulnerability assessment was not completed within 6 days of admission (resident file numbered 5);

e. The cultural screening was not completed (resident file numbered 5);

f. The gender specific needs screening was not completed (resident file numbered 5); and

g. The screenings did not include inquiries and the results of the inquiries regarding the degree to which the resident’s family desires to be involved during the resident’s stay at the facility (resident files numbered 1, 2, 4, and 5).

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

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

25. Violation: Four of four resident files reviewed for rules governing program services did not meet requirements. The license holder did not have documentation to demonstrate that they offered services to support the resident and family in learning how to plan and participate in recreation and leisure activities (resident files numbered 1, 2, 4, and 5) or vocational skill development (resident files numbered 1, 2, and 5).

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 6 and 2960.0590, items E and G.

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

26. Violation: Four of four resident files reviewed for rules governing treatment plans did not meet requirements. The license holder did not include the use of psychotropic medications in the resident’s individual treatment plan (resident files numbered 1, 2, 4, and 5).

Rule Violated: Minnesota Rules, part 2960.0620, subpart 1, item A.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

27. Violation: Four of four resident files reviewed for rules governing service plan reviews did not meet requirements. There was not documentation to show that the individual abuse prevention plan for a vulnerable adult was reviewed as a part of the service plan review (resident files numbered 5 and 7) and the individual treatment plan was not reviewed by an alcohol and drug counselor every two weeks (resident files numbered 1 and 4).

Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 2960.0490, subpart 5.

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

28. Violation: Two of four resident files reviewed for rules governing health care did not meet requirements. The license holder did not have documentation to support that they contacted a newly admitted resident’s prescriber to verify information regarding the resident’s prescriptions (resident file numbered 2) or that they noted the quantity initially received from the pharmacy for a resident who received prescription drugs at the facility (resident file numbered 4).

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

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

29. Violation: Four of four resident files reviewed for rules governing psychotropic meds did not meet requirements in the following ways:

a. The license holder did not have documentation that they monitored for side effects for residents prescribed a psychotropic medication at least weekly for the first six weeks and then quarterly thereafter (resident files 1 and 2) using standardized checklists or rating scales (resident files numbered 1, 2, 4, and 5);

b. The license holder did not have documentation to demonstrate that they conducted a psychotropic medication review at least monthly for the first six months and at least quarterly thereafter (resident files numbered 1, 2, 4, and 5).

Rule Violated: Minnesota Rules, part 2960.0620, subparts 2 and 5.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

30. Violation: Three of four resident files reviewed for rules governing informed consents did not meet requirements in the following ways:

a. The license holder did not have documentation that they obtained consent before any nonemergency administration of psychotropic medication (resident file numbered 2);

b. The license holder did not have documentation to demonstrate that the following information was communicated both orally and in writing to the resident’s legal guardian and the resident regarding the prescribed psychotropic medication (resident files numbered 4 and 5):

i. The diagnosis and level of severity of the symptoms and behaviors for which the medication is prescribed;

ii. Expected benefits of the medication;

iii. Pharmacological and nonpharmacological treatment options available and the course of the condition with and without the treatment options;

iv. Specific information about the medication to be used, including the generic and commonly known brand name, the route of administration, the estimated duration of therapy, and the proposed dosage range or maximum dose;

v. The more frequent and less frequent but serious side effects of the medication, including how the risks and possible side effects must be managed;

vi. An explanation that consent may be refused or withdrawn at any time and that consent is time limited and automatically expires in 30 days for verbal consent and annually for written consent; and

vii. The names, addressed, and telephone numbers of appropriate professionals to contact if questions or concerns arise.

Rule Violated: Minnesota Rules, part 2960.0620, subparts 6 and 7.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

31. Violation: Three of three resident files reviewed for rules governing the use of restrictive procedures did not meet requirements. The license holder did not meet requirements in these ways:

a. There was not documentation that staff contacted the mental health professional or program director to inform them of the use of physical holding no later than 30 minutes after initiating the physical hold for the following dates:

i. March 31, 2024 (resident file numbered 3); and

ii. July 7, 2024 (resident file numbered 6).

b. The staff person that implemented the emergency use of physical holding on March 31, 2024, did not document its use immediately after the incident concluded; the incident was not documented as a restrictive procedure (resident file numbered 3); and

c. The license holder did not have documentation that an administrative review was completed within three working days after the use of the restrictive procedures on April 12, 2024, and April 25, 2024 (resident files numbered 3 and 8).

Rule Violated: Minnesota Rules, parts 2960.0710, subparts 6, items E, G, and K, and subpart 10.

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

32. Violation: Two of two resident files reviewed for rules governing no-ejects did not meet requirements. The license holder did not have documentation that during the no-eject review process the license holder determined whether the license holder, treatment team, interested persons, or the resident could develop additional strategies to resolve issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder (resident files numbered 4 and 6).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure their use of no-ejects meets all applicable requirements.

33. Violation: Three of four resident files reviewed for rules governing discharge procedures did not meet requirements. The license holder did not have documentation of a signed receipt at discharge by the resident that all of their personal property was returned (resident files numbered 1, 4, and 5).

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3.

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

34. Violation: Three of four resident files reviewed for rules governing transition services plans did not meet requirements. There was not documentation that the plan considered the environment into which the resident was discharging to and recommendations for how the resident may deal with issues and potential challenges within that environment (resident files numbered 4, 5, and 8) or that a copy of the plan was given to the resident (resident file numbered 8).

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

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

35. Violation: Eight of eight resident files reviewed for rules governing discharge documentation did not meet requirements. The license holder did not document:

a. The extent to which a resident’s stay in the facility met the goals and objectives identified in the resident’s treatment plan (resident file numbered 5);

b. The services identified in the resident’s treatment plan that were provided to the resident directly by the license holder and the services that were provided by a provider other than the license holder and who provided the services (resident files numbered 1, 4, 9, 10, 11, and 12);

c. The extent to which the services provided the resident contributed to achieving the goals and

objectives identified in the resident’s treatment plan (resident files numbered 4, 5, 9, 10, 11,

and 12);

d. The development of a discharge plan at least ten days prior to discharge that includes arranging for appropriate follow up care in the community and written notification of the discharge to the resident’s legal guardian (resident file numbered 5).

Rule Violated: Minnesota Rules, parts 2960.0140, subpart 2, items A and B, and 2960.0190, subpart 2, item A.

Repeat Violation: In a Correction Order that DHS issued on June 10, 2022, you were previously found in violation of this same rule.

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

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Final Agency Decision

As stated above, this amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated December 2, 2024. As such, the decision is not subject to appeal.

Legal Authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 2.

Questions

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

Sincerely,

Hannah Horsch, Licensor

Licensing Division

Office of Inspector General

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


report_date: February 6, 2025

raw_content:
February 6, 2025

Annie Gendaszek, Authorized Agent

Minnesota Health Operations

3990 Hillsboro Pike, Suite 330

Nashville, TN 37215

License Number:   1108472 (CRF)

Report No.:     202310733

Dear Annie Gendaszek:

On December 23, 2024, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citation 5 in the Correction Order issued to you by the Department of Human Services on December 2, 2024. You also provided information about the timeline to provide submissions for citation 9, but you did not provide information to indicate you disagree with the issuance of citation 9. Because you requested reconsideration only of citation 5, the remaining citations are final and not within the scope of this review.

Citation 5: Violation: The license holder’s restrictive procedures policy did not address prone positions or contraindicated physical restraints. The license holder was not assessing residents for any contraindications due to known medical or psychological conditions.

Request for Reconsideration. You submitted a letter and supporting documentation to support your belief that the citation was incorrect.

Reconsideration Determination. Under Minnesota Statutes, section 245A.211, subdivision 3, paragraph (b), a license holder must not use a prone restraint on any person receiving services in a program, except in specified instances which includes that if a person rolls into a prone position during the use of a restraint, the person must be restored to a nonprone position as quickly as possible.

Under subdivision 4, a license holder must not implement a restraint on a person receiving services in a program in a way that is contraindicated for any of the person’s known medical or psychological conditions. Prior to using restraints on a person with known medical or psychological conditions that restraints are contraindicated for, the license holder must document the contraindication and the type of restraints that will not be used on the person based on this determination.

After further review of the file and of the information provided by the license holder, the Commissioner has determined the program met the statutory requirements regarding citation 5, and the citation should be rescinded.

Disposition: The Commissioner has reviewed the license holder’s request for reconsideration and all the information submitted in response to the correction order. The Commissioner finds there is not sufficient evidence to support citation 5, and the citation is rescinded.

This is a final agency decision.

Sincerely,

Frances Simon Standing, Attorney

Legal Counsel’s Office

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/