raw_content:
April 23, 2024

Jack Benson, Authorized Agent

On-Belay of Minnesota Inc

115 Forestview Ln. N

Plymouth, MN 55441

License Number: 800099 (CRF)

CORRECTION ORDER

Dear Jack Benson,

On January 31, 2023, an Order of Conditional License, dated August 12, 2022, was affirmed by the Department of Human Services (DHS), Division of Licensing, for your program. In addition to the licensing rules and statutes, an Order of Conditional License also includes terms that the license holder must comply with.

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 not complying with terms of the Conditional License. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

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

Violation: The license holder failed to comply with term 5 of the Order of Conditional License. The license holder failed to submit documentation to DHS Licensing of the results of monthly self-monitoring reviews, including discrepancies found and corrective actions taken for the months of November and December 2023 and January 2024. The documentation was due February 15, 2024, and has yet to be received.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that all terms of the order of conditional license are followed.  Within 15 days of receipt of this order, submit the required documentation of the monthly self-monitoring reviews for the months of November and December 2023 and January 2024.

If you fail to correct the violations specified in the correction order within the prescribed timelines, additional sanctions may be issued per Minnesota Statutes, section 245A.06 and/or 245A.07.

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

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

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 me as soon as possible.

Sincerely,

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


state: MN

facility_name: On-Belay House

report_date: December 4, 2023

raw_content:
December 4, 2023

Jack Benson, Authorized Agent

On-Belay of Minnesota Inc

115 Forestview Ln. N

Plymouth, MN 55441

License Number: 800099 (CRF)

Investigation Report Numbers: 202209066

202301933

CORRECTION ORDER

Dear Jack Benson:

On October 2 through 4, 2023, a licensing review and licensing investigations of On-Belay House located at 115 Forestview Ln. N., Plymouth, MN 55441, 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 chemical dependency services under Minnesota Rules, parts 2960.0430 through 2960.0490. 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.

Physical Plant, Policies, and Practices

1. Citation: Minnesota Rules, parts 2960.0050, subpart 1, item H; 2960.0110, subparts 2 and 3, items A and D; and 2960.0200, item A.

Violation: The license holder failed to ensure the physical environment met the needs of the residents and their right to live in clean and safe surroundings:

a. The physical environment did not provide for the comfort and dignity of residents as it did not provide all residents access to comfortable seating options in group and lounge areas and there was offensive graffiti on the bathroom stalls;

b. Maintenance was not operated on a consistent and healthy basis. A DHS Licensor observed mold build-up in a toilet that was out of service; and

c. The fixtures were not kept in good repair. A DHS Licensor observed a broken metal furnace frame and the back of a clothing wardrobe was broken off with nails sticking out.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the physical environment meets requirements. Within 30 days receipt of this order, submit verification that the items above were corrected to demonstrate compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

2. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, parts 2960.0050, subpart 1, item J; 2960.0080, subpart 4, item B, subpart 5, item A, and subpart 15, items A and B; and 2960.0160, subpart 4, item A.

a. Violation: The license holder did not maintain policies and procedures necessary to maintain compliance with licensing requirements. During the on-site licensing review it was determined that the resident right to reasonable communication and visitation was restricted through a practice referred to as Black-Out Week or Client Orientation Week. Requirements were not met in the following ways: The practice of Black-Out Week and Client Orientation Week was not described and included in the copy of facility rules that were provided and explained to the residents upon admission;

b. The license holder’s use of Black-Out Week and Client Orientation Week did not ensure the residents’ rights to reasonable communication and visitation with family and unrestricted visitation with parents were protected; and

c. The license holder did not include the consequences used in practice that are applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior in the copy of facility rules.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of facility rules meets requirements. Within 30 days receipt of this order, submit a revised discipline policy and a copy of facility rules provided to residents that demonstrates compliance.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

3. Citation: Minnesota Statutes, section 245A.65, subdivision 1 and Minnesota Rules 2960.0080, subpart 17, items B through D.

Violation: The vulnerable adult and maltreatment of minors reporting policies and procedures did not meet requirements in the following ways:

a. The vulnerable adult reporting policy did not include:

1) The internal review must include an evaluation that the policies and procedures were adequate and if there was a need for additional staff training; and

2) The identification of the Minnesota Adult Abuse Reporting Center (MAARC) as the common entry point to report suspected maltreatment to;

b. The maltreatment of minors reporting policy did not include:

1) Accurate procedures to follow when reporting suspected maltreatment of a minor. The policy consisted of multiple reporting procedures, each contradictory to the other and allowed for an internal report to be made; and

2) That a person mandated to report child maltreatment occurring within a licensed facility must report the information to the Department of Human Services, which is the agency responsible for licensing the facility; and

c. The license holder did not meet the reporting requirements of Minnesota Statutes, chapter 260E when reporting incidents of suspected maltreatment of a minor that occurred within their licensed facility. The incidents were not reported to DHS, the agency responsible for licensing the facility (April 21, 2023, July 1, 2023, and August 18, 2023).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the policy and procedures for reporting maltreatment of vulnerable adult and minors meets all applicable requirements. Within 30 days receipt of this order, submit revised maltreatment reporting policies and procedures that demonstrates compliance.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

4. Citation: Minnesota Rules, part 2960.0050, subpart 1, item O.

Violation: The license holder failed to ensure resident rights were protected. Through review of resident and facility documentation and staff and resident interviews, DHS Licensors determined that residents were being assigned to “super clean” multiple areas of the building that were not for therapeutic purposes and consistent with the resident’s treatment plan. 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.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the rights of residents are protected.

5. Citation: Minnesota Statutes, section 245A.66, subdivision 1.

Violation: The license holder’s internal review of alleged or suspected maltreatment of minors did not meet requirements. There was no documentation of an internal review completed for the following reports of alleged or suspected maltreatment made on the following dates:

a. March 8, 2023;

b. April 21, 2023;

c. July 1, 2023; and

d. August 18, 2023

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

6. Citation: Minnesota Rules, parts 2960.0450, subpart 2, item D and subpart 4.

Violation: The license holder’s implementation of therapeutic recreation treatment services did not meet requirements. Services were not led by, directed by, or provided according to a plan developed by a qualified alcohol and drug counselor.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure treatment services provided meet all applicable requirements. Within 30 days receipt of this order, submit a therapeutic recreation plan that demonstrates compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

7. Citation: Minnesota Rules, parts 2960.0150, subpart 4.

Violation: The license holder did not develop an annual training plan to demonstrate the in-service training offered for employees relevant to the population being served.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of training meets all applicable requirements. Within 30 days receipt of this order, submit an annual training plan that demonstrates compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

8. Citation: Minnesota Rules, part 2960.0150, subpart 3, item G.

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. January 3, 2023;

b. January 11, 202;

c. February 7, 2023;

d. February 8, 2023;

e. March 6, 2023; and

f. March 10, 2023.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the minimum staff to resident ratios meet all applicable requirements. Within 30 days receipt of this order, submit the staff schedule with the corresponding daily resident census for the previous, consecutive two weeks that demonstrates compliance.

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

9. Citation: Minnesota Rules, section 2960.0080, subpart 17, item A.

Violation: The license holder’s reporting of critical incidents did not meet requirements. The following dates included incidents that met the definition of a critical incident and were not reported to DHS:

a. September 11, 2023 included a serious resident injury; and

b. August 29, 2023 included alleged sexual misconduct.

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

Personnel Files

10. Citation: Minnesota Rules, parts 2960.0150, subpart 2 and 2960.0460, subpart 5, item A.

Violation: One of two files reviewed for alcohol and drug counselor qualifications (personnel file numbered 6) did not meet requirements. The file did not contain a current copy of their license to demonstrate the staff person was licensed.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of an alcohol and drug counselor’s qualifications meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required.

11. Citation: Minnesota Rules, part 2960.0460, subpart 6a, item A.

Violation: One personnel file reviewed for requirements governing supervision of an individual with a temporary permit (personnel file numbered 6) did not meet requirements. The file did not contain documentation to demonstrate that the staff person received supervision at least weekly by an LADC from January 31, 2023, through July 8, 2023.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of supervision for individuals with a temporary permit meets all applicable requirements. Within 30 days of receipt of this order, submit supervision documentation of an individual with a temporary permit for November and December 2023 to demonstrate compliance.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

12. Citation: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0070, subpart 5, and 2960.0100, subparts 3, item A and 5.

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

a. The staff person was not oriented on the administration of resident admission screenings when responsible for administering screens (personnel files numbered 1 and 2);

b. Documentation did not demonstrate the staff person received orientation to:

1) The following topics before having unsupervised contact with residents (personnel files numbered 1, 3, and 4):

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

ii. Operational policies and procedures of the license holder; and

2) The program’s internal policies and procedures on maltreatment reporting within 72 hours of first providing direct contact services to residents (personnel files numbered 1, 3, and 4); and

c. Documentation did not include the date, number of hours, and the name of the entity/person(s) providing the training for each topic area (personnel files numbered 1, 3, and 4).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit a template for documenting orientation training to demonstrate compliance.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

13. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0100, subparts 3, items A and B, 5, and 2960.0150, subpart 4, item B.

Violation: Two of two personnel files reviewed for requirements governing ongoing training (personnel files numbered 2 and 5) 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;

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

3) At least 24 hours of in-service training for the annual year; 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.

Corrective Action Ordered: Effective immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

Resident Files

14. Citation: Minnesota Rules, part 2960.0070, subpart 3, item B.

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

a. The residents’ written language;

b. A description of assets and strengths of the resident, and if available, related information from the resident, resident’s family, and concerned persons in the resident’s life; and

c. The placing agency’s case plan goals for the resident.

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

15. Citation: Minnesota Rules, part 2960.0160, subpart 2, items A and C.

Violation: Two of three resident files reviewed for requirements governing admission criteria (resident files numbered 2 and 3) 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.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

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

Violation: One of three resident files reviewed for requirements governing the inventory of personal property (resident file numbered 3) did not meet requirements. The inventory was not signed by the license holder or the resident upon admission.

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

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

17. Citation: Minnesota Rules, part 2960.0070, subpart 5, item C.

Violation: Two of three resident files reviewed for requirements governing admission screenings (resident files numbered 1 and 2) did not meet requirements. The health screening did not include the required information for the resident’s most recent physician and clinic.

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

Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in an Order of Conditional License dated August 12, 2022.

18. Citation: Minnesota Rules, part 2960.0490, subparts 2, 3, items A, C, D, and F, and 5.

Violation: Three of three resident files reviewed for requirements governing treatment plans and treatment plan reviews 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 (resident files numbered 1 and 2);

b. The plan did not begin upon the completion of the comprehensive assessment (resident file numbered 2);

c. Resources to which the resident was referred to for problems to address concurrently outside of the program and the reason for the referral were not addressed in the plan (resident files numbered 1 through 3);

d. The objectives were not time limited or measurable (resident files numbered 1 through 3);

e. Specific intervals for which resident progress was to be reviewed was not included in the plan (resident files numbered 1 through 3);

f. The minimum outcomes that were to be met before the resident discharged were not included in the plan (resident files numbered 1 and 2);

g. The treatment plan was not reviewed at least every two weeks from August 8 through August 24, 2023 (resident file numbered 1); and

h. Specific services did not change when expected outcomes were not being achieved (resident files numbered 1 and 2).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plans meet all applicable requirements. Within 30 days receipt of this order, submit one initial Treatment Plan and a concurrent updated Treatment Plan for one resident to demonstrate compliance.

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

· Order of Conditional License dated August 12, 2022

· Correction Order dated June 16, 2020

B. Recommendations

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

1. It is recommended that the license holder conduct a thorough review of their policies and procedures and revise as needed based upon their evaluation of: accuracy to current regulatory requirements, current implementation of program procedures and practices, meeting the needs of the population being served in present day, health and safety policies and procedures for both residents and staff, employee performance policies, duplication, redundancy, and written in plain language;

2. It is recommended that the license holder offer and require professional Clinical Documentation education and training for their clinical staff who provide and write documents to treatment services; and

3. It is recommended that the license holder create a formalized hiring and training system that includes the following:

i. A written guide that includes all licensing requirements involved around the hiring of staff persons in relation to background studies, qualifications for specific positions, documentation required in a personnel file, and vetting new employees;

ii. Training curriculums;

iii. Protocols for specific practices and job duties;

iv. Training competencies for trainings provided;

v. Training/competency checklist specific to each position; and

vi. In-person trainings that allows for an interactive experience.

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

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

1. By secure email to: 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

C. Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Tina Christensen, Human Services Senior Licensor

Licensing Division

Office of Inspector General

651-431-6610

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


report_date: January 31, 2023

raw_content:
January 31, 2023

Jon Benson, Authorized Agent

On-Belay House

115 Forestview Lane N.

Plymouth, MN 55441

License Number: 800099

Dear Jon Benson:

This matter arises from an Order of Conditional License, dated August 12, 2022, issued after a licensing review conducted June 6 through 8, 2022 (See attached Exhibit A). On August 24, 2022, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration of the Order of Conditional License.

You requested reconsideration of the following citations: 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 25, and 31. You did not request reconsideration of the remaining citations, and those citations are therefore final and not included in the scope of this review.

A. CONDITIONAL LICENSE DISPUTED, YOUR RECONSIDERATION REQUEST REGARDING STATUTORY CITATIONS AND LICENSING VIOLATIONS, AND DHS’ RESPONSE

1. Citation 1: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g), 245C.04, subdivision 11; and 245A.07, subdivision 3, paragraph (d).

Violation: As a result of a licensing review, a DHS licensor determined that you failed to request background studies (BGS) for nine of twenty-five staff persons before they began working in positions allowing direct contact with residents, or before an adult, regardless of whether or not the individual will have direct contact with persons served by the children residential facility, began working in the facility or setting.

a. Staff person (SP4) began a position working in the facility which allowed direct contact with persons served by the program on August 10, 2021. However, the license holder did not submit a BGS study request to DHS for SP4 until August 12, 2021.

Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d) , except for BGS violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a BGS violation before the commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a BGS violation may not avoid a fine for a subsequent BGS violation unless at least 365 days have passed since the license holder self-corrected the earlier BGS violations.

b. Although the license holder exercised the provisions of Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d) for SP4 on August 12, 2021, at least 365 days have not passed since the license holder self-corrected a BGS violation; therefore, the following are BGS violations. At the time of the licensing review, June 6 through 8, 2022, it was determined that the license holder did not submit a background study before an adult, regardless of whether or not the individual will have direct contact with persons served by the children residential facility, begins working in the facility or setting for the following:

1) SP7 began a position working in the facility April 14, 2022; however, the license holder did not submit a BGS request until June 3, 2022;

2) SP8 began a position working in the facility January 20, 2022; however, the license holder did not submit a BGS request until June 2, 2022;

3) SP9 began a position working in the facility April 1, 2022; however, the license holder did not submit a BGS request until June 2, 2022;

4) SP10 began a position working in the facility August 30, 2021; however, the license holder did not submit a BGS request until June 3, 2022;

5) SP13 began a position working in the facility January 31, 2022; however, the license holder did not submit a BGS request until March 3, 2022;

6) SP14 began a position working in the facility May 21, 2022; however, the license holder did not submit a BGS request until June 3, 2022;

7) SP16 began a position working in the facility August 30, 2019; however, the license holder had not initiated a BGS. The license holder was given notice to immediately remove SP16 from working in the facility on June 6, 2022;

8) SP17 began a position working in the facility May 5, 2022; however, the license holder did not submit a BGS request until June 3, 2022; and

9) SP19 began a position working in the facility May 30, 2022; however, the license holder did not submit a BGS request until June 7, 2022.

In addition, during the review, an administrative staff person (SP20) was unable to accurately describe the background study requirements for which they were responsible.

Repeat Violation: This is s repeat violation. In a Correction Order issued by DHS on May 19, 2020, you were found to be in violation of the same statutes.

Your request for reconsideration On-Belay House indicates in its reconsideration request that the background studies process was started prior to any and all employees having their first client contact. The program also provided copies of NetStudy 2.0 payment confirmations and email exchanges between the license holder and the payer.

DHS’ response: Although the program had initiated background studies, the record does not indicate the program had actually finished the process by submitting completed background study requests prior to allowing staff persons to begin working and have direct contact with clients. An actual submission of a completed background study request is required under Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g) and subdivision 11. Because the record supports the citation, it is affirmed.

2. Citation 3: Minnesota Rules, part 2960.0460, subpart 3.

Violation: The program director did not appear to know and understand the implications of Minnesota Rules, parts 2960.0010 to 2960.0710 and Minnesota Statutes, chapter 260E and section 626.557. During the licensing review, the program director (SP21) demonstrated a lack of knowledge and understanding of many licensing requirements identified above that govern the program, and often deferred to other administrators as having the better understanding.

Your request for reconsideration: On-Belay House states in its reconsideration request that the program director has extensive knowledge of the inner workings of the facility but believes it is best professional practice to defer to other staff persons who are focused in specific areas. The program indicates the belief that expecting the program director to have expert knowledge in every aspect of the program, documentation, policies and inner workings of the program is unfair and biased.

DHS’ response: Under Minnesota Rules, part 2960.0460, subpart 3, in addition to meeting other required staff qualifications, a program director must know and understand the implications of parts 2960.0010 to 2960.0710 and Minnesota Statutes, chapter 260E and section 626.557. Although it may be beneficial to have certain positions focus on specific areas, that focus does not eliminate either the program director’s responsibility to oversee the operations of the program or the rule requirement that the program director known and understand the implications of the rules and statutes related to the operation of the program. As a result, the record supports the citation, and it is affirmed.

3. Citation 4: Minnesota Rules, part 2960.0460, subpart 5, items B and C.

Violation: Two of two files reviewed for alcohol and drug counselor qualifications did not demonstrate that the staff persons had an additional 30 hours of classroom instruction in adolescent development and 150 hours of supervised experience as an adolescent alcohol and drug counselor (SP1 and SP2).

Your request for reconsideration On-Belay House indicates in its reconsideration request that within 24 hours of the audit exit interview, information regarding SP2’s 30 hours of classroom training and 150 hours of supervised experience was sent to the licensor.

DHS’ response: Although the license holder did submit training information regarding the 30 hours of classroom training for SP2, the document does not include the number of hours or demonstrate that training was completed. Additionally, the citation was also issued because there was no information to demonstrate that SP1 had an additional 30 hours of classroom instruction in adolescent development and 150 hours of supervised experience as an adolescent alcohol and drug counselor. Because the record supports the citation, it is affirmed.

4. Citation 5: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a) and Minnesota Rules, part 2960.0080, subparts 4, item A, and 5, item A.

Violation: During the licensing review a DHS licensor determined, through resident interviews and interactions with administrative staff persons, that the license holder had been utilizing disciplinary practices that the license holder failed to describe in a policy, which is necessary to maintain compliance with licensing regulations. Practices not included in policy are the following:

a. House Retreats/Restrictions, was described as requiring each youth to remain in their rooms and all programming stops for an extended amount of time while the staff conduct an internal investigation in response to a youth(s) behavior(s) that impact the milieu. During a resident interview, the resident relayed information that they were on house restrictions for an entire weekend; and

b. Color System, was described as a type of behavior management system for identifying levels of consequences and privileges for the resident. DHS licensors observed a white board in the group room which displayed the use of this practice.

Repeat Violation: This is a repeat violation. In a Correction Order issued by DHS on June 16, 2020, you were found to be in violation of the same statute.

Your request for reconsideration On-Belay House indicates in its reconsideration request that within 24 hours of the licensing review, the license holder sent the revised policies to the DHS licensor to better define the disciplinary practices that referred to house retreats/restrictions. The license holder indicates the policy was rewritten during the time of the audit.

DHS’ response: Although the license holder submitted a revised policy, a review of the policy and other documentation provided indicated it did not meet requirements. Because the record supports the citation, it is affirmed.

5. Citation 6: Minnesota Rules, part 2960.0150, subpart 3, item G.

Violation: For the week reviewed, May 22, 2022 to May 28, 2022, for requirements governing staff ratios, the license holder failed to ensure at least one direct care staff was present for every twelve residents during awake hours on the following dates and shifts:

a. On May 25, 2022, one staff scheduled for the morning shift with a census of 15 residents;

b. On May 27, 2022, one staff scheduled for the morning shift with a census of 15 residents; and

c. On May 28, 2022, one staff scheduled for the evening shift with a census of 15 residents.

Your request for reconsideration: On-Belay House indicates in its reconsideration request that staff ratios on all dates reviewed were met according to licensing requirements, which included utilizing other staff persons that are on site. The program also indicates that the DHS licensor did not inform or inquire of the license holder aboutf the discrepancies to give an opportunity to provide further documentation.

DHS’ response: However, the copies of the schedules provided with the request for reconsideration do not match the ones provided during the time of the review. During the licensing review, the licensor provided the opportunity to produce timesheets or other documentation for verification, but no other documentation was provided during the remainder of the licensing review. The license holder did not demonstrate at the time of the review that they had the required amount of direct care staff present on May 27, 2022, and May 28, 2022. However, after review of the information provided, it has been determined that the license holder did demonstrate a sufficient amount of staff were present on May 25, 2022. Because the record supports the citation, it is affirmed, with the correction that violation a. citing May 25, 2022 as a violation date is removed.

6. Citation 7: Minnesota Rules, parts 2960.0110, subparts 2 and 3, items A and D, and 2960.0200, item A

Violation: The license holder failed to ensure the physical environment met the needs of the residents and was kept in good repair:

a. The physical environment did not provide for the comfort and dignity of residents as it contained minimal amounts of furniture and comfortable seating options in communal areas;

b. Storage and housekeeping were not operated on a consistent and healthy basis. A DHS licensor observed mold in showers and unclean shower stalls, piles of clothes in the hallway on the floor, a mattress, bedframe, and broken laundry basket stored in the back hallway. In addition, the utility/storage room contained piles of garbage in corners; and

c. The fixtures were not kept in good repair. A DHS licensor observed broken, stained, and worn out toilet seats, a broken counter top in the kitchen, rust on the bathroom stalls, and a brown substance in the downstairs shower.

Your request for reconsideration: On-Belay House acknowledges in its reconsideration request that a storage room contained donated clothing and a broken bed frame and that there were piles of clothing in the hallway on the floor. The program indicates that since the visit, the facility has purchased new furnishings, replaced multiple fixtures and completed a deep clean of the building. The program also indicates general maintenance and repairs at the facility were temporarily limited due to CDC guidelines during the pandemic.

DHS’ response: While the license holder indicates action was taken after the licensing review, it does not dispute the conditions present at the time of the review and acknowledges conditions noted in the violation. Because the record supports the citation, it is affirmed.

7. Citation 8: Minnesota Rules, part 2960.0080, subpart 11, items D and E.

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

a. The license holder did not complete medication verification upon admission for a resident who was admitted with prescribed medications (R1);

b. The medication verification did not include the symptoms that the medication will alleviate and the symptoms that would warrant consultation with the physician (R3 and R5); and

c. Documentation to demonstrate the record keeping of the quantity of medications initially received from the pharmacy was not provided (R1 and R5).

Your request for reconsideration On-Belay House indicates in its reconsideration request that information was missed during the licensing review and that the program had paperwork showing that a medical intake was done. Although some of the information had not yet been uploaded digitally, hardcopies were available if requested and could have been provided at the time of the review. The program submitted documentation showing that the medical portion of intakes were completed.

DHS’ response: Although documentation was provided with the program’s reconsideration request, the DHS licensor asked the license holder and the program’s nurse for the information during the licensing review. Under Minnesota Statutes, section 245A.04, subdivision 5(a), the commissioner must be given access to documents and records, without prior notice and upon request without prior notice. This allows licensing to ensure the necessary records and documentation is complete and available to staff who rely on it for their daily work. Because the documentation was not produced at that time, the record supports the citation, and it is affirmed.

8. Citation 9: Minnesota Statutes, sections 260E.06, subdivision 1; 260E.11, subdivision 1; 245A.65, subdivision 1, paragraph (b); and 245A.66, subdivision 1; and Minnesota Rules, part 2960.0080, subpart 17, item D.

Violation: The vulnerable adult and maltreatment of minors reporting policies and procedures did not meet requirements in the following ways:

a. The vulnerable adult reporting policy did not include:

1) The secondary person or position to whom internal reports may be made and is responsible for forwarding internal reports to the common entry point; and

2) The internal review must include an evaluation that the policies and procedures were adequate and if there was a need for additional staff training;

b. The maltreatment of minors reporting policy did not include:

1) The correct information for where the mandated reporter is to immediately report the information to. In addition, the policy indicates to report to the common entry point which is the reporting center for vulnerable adults, not minors;

2) A person mandated to report child maltreatment occurring within a licensed facility shall report the information the Department of Human Services;

3) The accurate use of referencing children or minors where appropriate versus referencing vulnerable adults;

4) The secondary person or position who will ensure internal reviews are completed; and

5) Consistent processes for meeting requirements. The policy contains contradictory and duplicate processes; and

c. The license holder did not review policies and procedures about maltreatment at least annually and revise the policies if the maltreatment laws change, as evidenced by not referencing Minnesota Statute 260E, Maltreatment of Minors

Repeat Violation: This is a repeat violation. In Correction Orders issued by DHS on June 16, 2020, and March 6, 2018, you were found to be in violation of the same statute.

Your request for reconsideration: In the request for reconsideration, On-Belay House references its policies and procedures in indicating that their policies and procedures met requirements. Specifically, the program references violation b, item 4, which indicated that the maltreatment of minors reporting policy did not include the secondary person or position who will ensure internal reviews are completed.

DHS’ response: After review of the information provided, it has been determined that there is not sufficient evidence to support violation b, item 4, and that violation is rescinded.

It has also been determined that although cited requirements are included in the policy under “internal review,” other requirements are listed under “internal reports.” As a result, violation a, item 2, is amended to reflect the contradiction in the policy and that the internal review requirements did not include the following: that it is to be completed within 30 days; that corrective action will be taken as necessary to protect the health and safety of vulnerable adults; an evaluation of whether the reported event is similar to past events or services involved; and that based on the results of the review, the license holder will develop, document and implement a corrective action plan designed to correct the current lapses and prevent future lapses in performance. Because the record supports the citation, it is affirmed with the amendment noted above and with the exception of violation b, item 4. Also, the citation is amended to include Minnesota Statutes, section 245A.04, subdivision 14, paragraph (a) as additional authority for the violation.

9. Citation 10: Minnesota Statutes, section 245A.66, subdivision 1.

Violation: The license holders’ internal review of alleged or suspected maltreatment of minors, for incidents dated January 25, 2021, and February 17, 2022, did not meet requirements in the following ways:

a. The documentation for the incident dated January 25, 2021, did not include:

1) A date to determine the internal review was completed within 30 days;

2) An evaluation of whether:

i. The policies and procedures were followed;

ii. The policies and procedures were adequate;

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

3) Documentation that the internal review was completed; and

b. There was no documentation of an internal review complete for the incident dated February 17, 2022.

Your request for reconsideration: With its request for reconsideration, On-Belay House submitted a maltreatment investigation completed by a LADC at the program and indicated the investigation contained a detailed narrative of the incident that occurred on January 25, 2021. The license holder acknowledges that “specific boxes” that would indicate completion of the investigation were not specified and specific wording of the evaluation of the policies and procedures being followed and adequate was not identified. However, the program indicates other sections of the report contained the required information. With regard to the incident that occurred on February 17, 2022, the program indicates that although there was never an internal investigation completed, an internal review conducted on later dates would have been available if the program had been asked to provide it.

DHS’ response: However, the internal review for the incident that occurred on January 25, 2021, does not indicate the required components cited in the violation. With regard to the incident that occurred on February 17, 2022, DHS requested that the compliance administrator provide documentation of the internal review for the incident, and the program indicated the review could not be located at that time. As a result, the record supports the citation, and it is affirmed.

10. Citation 11: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a).

Violation: The program abuse prevention plan did not meet requirements in the following ways:

a. The need for specialized programs of care for clients was not addressed in the program abuse prevention plan; and

b. There was no documentation to demonstrate the plan was reviewed annually by the license holder’s governing body or delegated representative in calendar year 2021.

Repeat Violation: This is a repeat violation. In Correction Orders issued by DHS on June 16, 2020, and March 6, 2018, you were found to be in violation of the same statute.

Your request for reconsideration: With regard to violation a, On-Belay House cites a specific section of its abuse prevention plan, which indicates the program “will then make a referral to a specialized program to meet the needs of those clients.” The program indicates that the policy has since been corrected to include all of the regulation requirements.

DHS’ response: After further review, it has been determined that the license holder meets the requirements. As a result, there is not sufficient evidence to support the violation a, and it is rescinded. There was no dispute by the license holder regarding violation b, and it is affirmed.

11. Citation 12: Minnesota Statutes, sections 245A.65, subdivision 3 and 245A.19, paragraph (a), and Minnesota Rules, parts 2960.0460, subpart 8, item A, 2960.0010, subpart 3, item A, and 2960.0070, subpart 5.

Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements. The license holder did not provide the following training:

a. Before the staff person had 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 (SP1);

2) Cultural diversity, gender and cultural sensitivity, culturally specific services, information about discrimination and racial bias issues, general and special needs, including disability needs of residents and families served prior to direct contact with residents (SP1);

3) Maltreatment of minors reporting requirements (SP1);

4) Operational policies and procedures of the license holder, including the program’s drug and alcohol policy (SP1 and SP7);

5) Data practices regulations and issues (SP1); and

b. Within 72 hours of first providing direct contact services:

1) HIV/Minimum Standards orientation training (SP1); and

2) Vulnerable adult maltreatment reporting requirements, the program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (SP1);

c. Before conducting screens, training on the administration of screenings upon admission of residents (SP3); and

d. An overnight staff file did not contain documentation of their knowledge of and ability to perform basic first aid procedures, including cardiopulmonary resuscitation and first aid for seizures, trauma, and fainting (SP7).

Repeat Violation: This is a repeat violation. In a Correction Orders issued by DHS on June 16, 2020, you were found to be in violation of the same statute.

Your request for reconsideration: On-Belay House indicated in its request for reconsideration that new hire documentation for SP7 was completed by the hiring supervisor on April 11, 2022. The program also indicates that SP1 was hired and completed all new hire training before having client contact. Although it was discovered that SP1’s entire employee file was missing, the file was re-created and SP1 signed an attestation indicating they had completed all training prior to having client contact.

DHS’ response: A review of SP1’s personnel file indicated a hire date of May 19, 2021, and the compliance administrator indicated during the licensing review that SP1 changed positions September 30, 2021, and the program was not able to explain why initial hire date orientation training documentation was not in the file. Also, the signed attestation note was not in the personnel file at the time of the review. Additionally, SP7’s personnel file indicated a signed attestation of the license holder’s alcohol and drug policy, which is included as part of the license holder’s practice, was missing from the personnel file. Also, the program’s document regarding orientation and training for new employees did not reflect that training, and there was no documentation in the file regarding knowledge of the ability to perform basis first aid procedures, including cardiopulmonary resuscitation and first aid for seizures, trauma and fainting. As a result, the record supports the citation, and it is affirmed.

12. Citation 13: Minnesota Rules, parts 2960.0100, subpart 5.

Violation: Seven of seven personnel files reviewed for requirements governing the documentation of annual and orientation training occurring did not meet requirements (SP1 through SP7). Documentation from January 2021 through June 5, 2022, did not consistently include the date, number of hours, and the name of the entity that provided the training in each topic area.

Repeat Violation: This is a repeat violation. In Correction Orders issued by DHS on June 16, 2020, and March 6, 2018, you were found to be in violation of the same statute.

Your request for reconsideration: On-Belay House indicates in its request for reconsideration that documentation regarding annual and orientation training was completed for all seven employees, and the documentation demonstrated the date, number of hours of training and the name of the entity that provided the training. Also, since the licensing review, the program revised training documentation to demonstrate that each individual topic with supporting documentation is completed and signed. The program attached the quarterly training document that specifies the date, hours of training and name of the entity that provided the specific training. Each employee has documented development training in their personnel file.

DHS’ response: However, under the applicable rule, the program is required to document the date and number of hours of orientation and in-service training completed by each staff person in each topic area along with the name of the entity that provided the training. The documentation provided by the program did not provide the required information. The checklist for orientation and training did not indicate the number of hours on the template, and the entity that provided the training was not included for every staff person. Additionally, the form regarding quarterly meeting minutes did not include the titles of the trainings. As a result, the record supports the citation, and it is affirmed.

13. Citation 14: Minnesota Statutes, sections 245A.65, subdivision 3, Minnesota Rules, parts 2960.0100, subpart 3, item A.

Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements (SP2, SP3, SP5, and SP6). The staff person did not receive the following annual training:

a. Vulnerable adults maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572;

b. The license holder’s program abuse prevention plans; and

c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

Repeat Violation: This is a repeat violation. In a Correction Order issued by DHS on June 16, 2020, you were found to be in violation of the same statute.

Your request for reconsideration: On-Belay House indicates in its request for reconsideration that the program reviews abuse prevention plans and internal policies and procedures related to prevention and reporting of maltreatment on a quarterly basis. The program indicates it has documentation that the staff persons listed in the citation attended a quarterly review that reviews vulnerable adult maltreatment reporting requirements, abuse prevention plans and policies related to the prevention and reporting of maltreatment of individuals receiving services. The program also indicates the documentation provided states the date of training, the training location, the time started, the time ended, the total hours completed, and the name of the entity that provided the training.

DHS’ response: However, although the license holder provided annual training documentation with the reconsideration request, the documentation was not contained in the staff persons’ personnel files and was not provided during the licensing review. Also, the license holder was also given 24 hours after the exit meeting to provide the training documentation. Training documentation provided for SP2 and SP5 did not demonstrate completion of the required trainings. As a result, the record supports the citation, and it is affirmed.

14. Citation 15: Minnesota Rules, part 2960.0080, subpart 14.

Violation: Four of four personnel files reviewed for requirements governing the emergency plan did not meet requirements (SP2, SP3, SP5, and SP6). The license holder did not review the facilities emergency plan once at least every six months for calendar year 2021.

Repeat Violation: This is a repeat violation. In a Correction Order issued by DHS on June 16, 2020, you were found to be in violation of the same rule.

Your request for reconsideration: On-Belay House indicated in its request for reconsideration that the citation is being appealed for a partial correction. The program indicates quarterly meetings regarding the emergency plan review had been completed for the second quarter of 2021 and the first quarter of 2022. The program indicates that due to challenges associated with the pandemic, the program was not able to conduct the quarterly training for the third and fourth quarters of 2021.

DHS’ response: However, documentation to demonstrate that the license holder’s facility emergency plan was reviewed at least once every six months for calendar year was not included within each staff person’s file and was not produced when requested or provided 24 hours after the exit meeting. As a result, the record supports the citation, and it is affirmed.

15. Citation 18: Minnesota Rules, part 2960.0090, subpart 2.

Violation: Two of two resident files reviewed for requirements governing no eject policy (R4 and R5) did not meet requirements in the following ways:

a. The license holder did not confer with other interested persons to review the issues involved in the decision to discharge the resident; and

b. The license holder determined 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.

Repeat Violation: This is a repeat violation. In Correction Orders issued by DHS on June 16, 2020, and March 6, 2018, you were found to be in violation of the same rule.

Your request for reconsideration: On-Belay House indicated in its request for reconsideration that it has documentation regarding R4 demonstrating that a meeting was requested with the probation officer, the resident’s mother, the resident, the program director and clinical staff. Additionally, the program indicates it has documentation indicating that the facility had conversations with the resident’s mother, and the client was supported by his probation officer and parents in his decision to not return to the facility.

DHS’ response: After further review, it was determined that the discharge did not meet the criteria to be a “no-eject.” As a result, the citation is amended to remove R4. As to R5, the record supports the citation, and it is affirmed.

16. Citation 19: Minnesota Rules 2960.0190, subparts 1, items A and B, and 2, items A and B.

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

a. The plan did not recommend ways to meet the resident's needs and identify resources available in the community to address the resident's continuing needs after release from the facility (R3 and R6);

b. The plan did not consider the environment the resident will return and recommend how the resident may deal with issues and potential challenges within the environment (R3 and R6);

c. The following elements of the plan were not included for the following resident files:

1) Budget plan, health services, and leisure activities (R3); and

2) Vocational services, rehabilitation services, financial status, and health services (R6);

d. Discharge documentation did not identify which services, including education, were provided directly or indirectly to the resident and who provided the services (R3); and

e. Discharge documentation did not identify the services, including education, that were recommended in the resident’s case plan or treatment plan but were not provided to the resident (R3 and R6).

Your request for reconsideration: On-Belay House indicated in its request for reconsideration that the files for both R3 and R6 contain clear and extensive documentation of the transitional service plans and discharge summaries and that the documentation was available at the time of the licensing review. The program also provided the documentation with its request for reconsideration.

DHS’ response: However, although the documentation was available at the time of the licensing review, it did not demonstrate that it met the required components as listed in items a through e of the violation. As a result, the record supports the citation, and it is affirmed.

17. Citation 20: Minnesota Rules, part 2960.0160, subpart 2, item C.

Violation: Two of four resident files reviewed for requirements governing admission criteria (R2 and R3) did not meet requirements. Before or at admission of a resident, the license holder did not document whether the program was able to meet the resident’s cultural, emotional, educational, mental health, and physical needs.

Your request for reconsideration: On-Belay House indicates in its request for reconsideration that the program completed cultural, gender specific, educational, vulnerability or sexual abusive behavior screenings and developed an initial service plan to assess resident needs. The program indicates the screenings are included in both resident files and that one file includes a health screening form that is absent in the other resident file. The program acknowledges that one file was missing a screening, but denies that multiple screenings were missed in all files.

DHS’ response: However, the citation did not relate to completing resident admission screenings under Minnesota Rules, part 2960.0070, subpart 5. Under Minnesota Rules, part 2960.0160, subpart 2, item C, before admission of a resident, the license holder must examine the placement agency’s information about the resident and must determine and document whether the program can meet the resident’s needs and must specifically document whether the program is able to meet the resident’s cultural, emotional, educational, mental health and physical needs. As a result, the record supports the citation, and it is affirmed.

18. Citation 25: Minnesota Rules, parts 2960.0490, subparts 3, item C, 4 and 5, and 2960.0450, subpart 2, item D.

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

a. The frequency of the intervention was not identified for every goal/intervention in the treatment plan (R2, R3, and R5);

b. The treatment plan was not reviewed at least every two weeks from November 26, 2021 through December 13, 2021 (R5);

c. There was no documentation of weekly reviews of services to indicate the type and amount of each service the resident received that week and whether the services have had the desired impact during the following time frames:

1) Admission to present time of licensing review (R1 and R2);

2) Admission to discharge (R3 and R5);

d. Documentation was not provided to determine if therapeutic recreation was provided for the following time frames:

1) Admission to January 2022 (R3); and

2) Admission to discharge (R5).

Repeat Violation: This is a repeat violation. In Correction Orders issued by DHS on June 16, 2020, and March 6, 2018, you were found to be in violation of the same rules.

Your request for reconsideration: On-Belay House indicated in its request for reconsideration of violation b that the documentation for the treatment plan for client R5 had been completed and reviewed on December 15, 2021, and the review covered December 1, 2021, to December 15, 2021.

DHS’ response: Under Minnesota Rules, section 2960.490, subpart 5, the individual treatment plan must be reviewed no less frequently than every two weeks. The effective date of the initial individual treatment plan was determined to be November 26, 2021, according to the signature and time stamp of the individual who completed the treatment plan, and the first treatment plan review is dated as December 15, 2021, for the review period of December 1, 2021 through December 15, 2021. Because the treatment plan review was not completed within two weeks from November 26, 2021, the record supports the citation, and it is affirmed with the amendment that the erroneous date of December 13, 2021, in the citation is corrected to the correct date of December 15, 2021.

19. Citation 31: Minnesota Rules, part 2960.0140, subpart 1, item A

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

a. Recreation, food, and sleeping accommodations provided to the resident;

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

c. Provisions for the resident’s safety.

Your request for reconsideration: On-Belay House indicated in its request for reconsideration that it was not out of compliance in conducting satisfaction surveys. The program notes that although recreation, food and sleeping accommodations were not listed on the satisfaction surveys, the surveys were revised to include those components and sent to the licensor within 24 hours of the licensing review.

DHS’ response: However, the citation was issued because the surveys did not contain the required components rather than because the program was not conducting the surveys. As acknowledged by the program, the surveys were missing components, and DHS did not receive a revised satisfaction survey template within 24 hours of the licensing review. As a result, the record supports the citation, and it is affirmed.

B. DISPOSITION

Based on the foregoing, the Commissioner finds that the citations in the August 12, 2022, Order of Conditional License are supported by the record, and they are affirmed, with the exception of: Citation 9, violation b, item 4 and citation 11, violation a, which have been rescinded.

Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program.

In its request for reconsideration, On-Belay House indicates the belief that the program should not be on a conditional license. In support of its position, the program indicates that it attempted in good faith to quickly remedy citations and demonstrates an eagerness to understand and comply with requirements. The program believes the conditional license is biased, and it believes that multiple citations were listed in error. The program also asks that consideration be given to the challenges faced by the program as a result of the pandemic. Also, the program indicates the conditional license would put undue stress on staff, the program’s referral system and the ability to strengthen and grow programs to an underserved population in the metro area. The program describes positive changes it has made to ensure the quality of care to residents, which include staffing changes and building upgrades.

The Commissioner appreciates that On-Belay House has taken steps to ensure compliance and acknowledges the difficulties that recent events may have caused for the license holder. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and determined that a conditional license is warranted. The Conditional Order cites thirty-three citations reflecting that On-Belay House has failed to comply with multiple requirements regarding: background studies requirements; staff qualifications, ratios, orientation and annual training; discipline policy and procedure requirements; facility environment and health services; supervision; maltreatment reporting policies and procedures; supervision; and resident transition and discharge. The license holder challenged only nineteen of the thirty-three citations on reconsideration, which resulted in only two citations being rescinded in part with all other citations being affirmed. The remaining citations along with the citations that were unchallenged support the need for a conditional license because they demonstrate a history of serious and chronic licensing violations that indicate a failure to follow requirements which affect the health, safety, and rights of clients.

The nature of the cited violations is also a basis for the conditional license. Multiple citations involved a failure to follow requirements which affected the health and safety of the persons served, including a failure to ensure staff met required qualifications, a failure to comply with staff ratios, a failure to ensure the environment is kept in good repair, a failure to comply with maltreatment reporting policies and procedures, and a failure to comply with requirements for transition and discharging a resident. Also, the license holder failed to meet requirements which resulted in violations that were severe in number and duration, including two citations involving failure to comply with background study requirements with one of those citations involving nine staff persons beginning a position working in the facility prior to the submission of a background study request. Background study requirements are in place to ensure the safety of the residents served by the program. Also, five citations related to a failure to comply with staff orientation and annual training requirements. Requirements regarding staff training and orientation are in place to ensure staff are familiar with policies and procedures related to resident safety and well-being and that staff are able to provide qualified care to those residents.

Additionally, the license holder failed to correct prior violations cited on multiple occasions. Sixteen of the thirty-three violations cited in the Conditional Order under review are repeat violations that were previously cited in a Correction Order dated June 16, 2020. Also, eight of the thirty-three violations are repeat violations similar to violations cited in a Correction Order dated March 6, 2018. The failure to correct a large number of citations strongly supports the need for a conditional license, the terms of which are focused on ensuring that the license holder is taking meaningful steps toward achieving compliance and thereby protecting clients’ health, safety, and rights.

Due to the need to monitor On-Belay House for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on August 12, 2022.

The period of the conditional license is two years, beginning on the date of this reconsideration decision. Because the terms of your conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter.

C. TERMS OF THE CONDITIONAL LICENSE

In addition to the licensing rules and statutes, you are required to comply with the following terms:

1. Within 14 days of receipt of this order, you must notify current residents and all parties who refer residents to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request.

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 treatment services. The notification to new residents must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file.

Within 30 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice.

2. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on rule requirements for 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. Individuals required to attend are the Program Director, Compliance Office, LADC Supervisor, RN, and Chief Operating Officer of On-Belay must attend the training offered by DHS Licensing. Training must be completed within 45 days of receipt of this order.

3. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on statute requirements for Background Studies under Minnesota Statute, chapter 245C. Individuals required to attend is your designated N2study sensitive information person and authorized agent. Training must be completed within 45 days of receipt of this order.

4. Within 14 days of receipt of this order, you must employ a staff person for the position of Compliance Officer. This staff person may not also hold the positons of Program Director or Alcohol and Drug Counselor Supervisor and must be consider at least 0.5 full-time Compliance Officer for license number 800099.

5. Within 30 days of receipt of this order, you must develop a self-monitoring tool and plan that assures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following:

a. Name and titles of those responsible to carry out duties within the plan; and

b. Procedure that includes a sample review of resident records, personnel files, required treatment services, treatment plans and reviews, medication administration records and medication verifications, incident reports, grievances, and monitoring of the implementation of policies and procedures on a monthly basis.

The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on November 12, 2022, February 12, 2023, May 12, 2023, and August 12, 2023 or until otherwise determined by DHS Licensing.

Submissions required by this order must be sent to:

Commissioner, Department of Human Services

ATTN: Katie Leuer

c/o Licensing Division

P.O. Box 64242

St. Paul, MN 55164-0242

651-431-6259

Your licensor will monitor your compliance with all applicable laws and rules. Verification of compliance may include unannounced visits. Failure to comply with the requirements in applicable rules and statutes, including Minnesota Statutes, chapter 245A (Human Services Licensing Act), Minnesota Statutes, chapter 245C (Human Services Background Study Act) and with the terms of your conditional license may result in further negative action, including revocation of your license.

This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115.

If you have any questions regarding the Order of Conditional License, please contact Katie Leuer, Unit Supervisor, at (651) 431-6259.

Sincerely,

Frances Simon Standing

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/

doc_type: Order