facility_name: Nexus Mille Lacs Family Healing

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

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

Report Number: 202400875

Date Issued: July 17, 2025

Name and Address of Facility Investigated:

Nexus Mille Lacs Family Healing
407 130th Avenue South
Onamia, MN 56359

License Number and Program Type:

Disposition:

Allegation One: Maltreatment determined as to sexual abuse and neglect of an alleged victim (AV1) by a staff person (SP).

Allegation Two: Maltreatment determined as to physical and neglect of an alleged victim (AV2) by the SP.

1036935-CRF (Children’s Residential Facility)

Investigator(s):

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

651-431-6572

Suspected Maltreatment Reported:

Allegation One: It was reported that a staff person (SP) allowed an alleged victim (AV1) to touch the SP’s leg, thigh, and buttocks, and give the SP a hug without stopping or addressing the interactions.

Allegation Two: It was reported that the SP slapped an alleged victim’s (AV2) mouth causing him/her to have a swollen lip.

Date of Incident(s):

Allegation One: January 15 and 20, 2024; and other dates unspecified

Allegation Two: January 20, 2024

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 20; subdivision 18, paragraph (a); and subdivision 23, paragraph (a):

"Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on February 16, 2024; from documentation at the facility; and through nine interviews conducted with AV1, AV2, AV1’s and AV2’s respective family members (FM1 and FM2), facility staff persons (the SP and P1), supervisory staff persons (P2 and P3), and a public-school employee (PSE).

The facility provided residential treatment for youth ages 10 to 18, who were needing additional support with emotional-, behavioral-, and mental health- needs. The facility provided supervision, therapy, medication management, recreation, and education.

The facility’s boundary and professionalism policies and procedures stated that staff should not engage in “red flag” behaviors, including:

· Spending notably more time with one youth to the exclusion of others.

· Allowing a youth to break rules.

· Sticking up for a youth against the rest of the staff.

· Creating situations of being physically isolated with a youth.

· Inappropriately touching a youth or allowing a youth to inappropriately touch the staff; this included on the leg, buttocks, sitting on a lap, etc.

· Talking sexually to or in front of a youth.

· Disclosing excessive personal information to a youth.

· “Rough housing,” tickling, pinching, etc., a youth.

Facility documentation stated that the SP, P1, P2, and P3 received training on the facility’s boundaries and professionalism policies and procedures including red flags, and on the Reporting of Maltreatment of Minors Act.

Allegation One: It was reported that the SP allowed AV1 to touch the SP’s leg, thigh, and buttocks, and give the SP a hug without addressing or stopping the behavior.

At the time of the incident, AV1 was 15 years old, and his/her diagnoses included attention-deficit hyperactivity disorder and disruptive mood disorder. AV1 wanted to work on emotional regulation and family reunification.

AV1 provided the following consistent information during separate interviews with the DHS investigator and with P2 for the facility’s internal investigation:

· AV1 “hung out” with the SP and “defended” the SP against other youth when it was alleged the SP made a “hated list” of youth names and rankings. AV1 never saw a list.

· The SP told AV1 that s/he was the SP’s “favorite youth.”

· One time, they were in the gym and the SP showed AV1 and other unidentified youth pictures of a “stripper” on the SP’s cellphone. The SP told them that s/he saw the stripper at a “strip club” and “smacked [the stripper’s] butt.”

· At least once, the SP held AV1’s hand.

· Once while playing basketball, an unidentified youth blocked a shot and accidentally struck AV1’s “nipple.” The youth then jokingly called the play “a breast block.” The SP heard this, approached AV1, and “caressed [the SP’s own] breast right in front of [AV1].” [Note: The word “breast” was used by AV1 to describe the incident and will later be used by others within this report; however, this should not be used as an indicator of the gender and/or the genitalia of anyone, including aV1 or the SP.]

· One time, the SP put his/her hand around AV1’s head and “put [AV1’s] head on [the SP’s] breast.” [Note: AV1 did not state whether there was clothing covering the SP’s breast. That said, there was no information the SP’s breast was exposed or unclothed.]

· One time, AV1 wanted to talk to the SP and the SP called him/her over to where the SP was sitting, which was on a gym mat on the floor with the SP’s legs outstretched. AV1 asked where s/he should sit and the SP said, “Here, just put your head on my leg.” AV1 then lay down next to the SP and put his/her head on the SP’s upper right thigh. While they were talking, the SP told AV1, “I’m sorry if it stinks down there.” AV1 asked, “What do you mean?” The SP said, “My [genitals]. I’m pretty sure it stinks.” AV1 did not smell anything.

· One time, AV1 was on the stairs taking two steps at a time and grabbed the railing but his/her hand swung forward and struck the SP’s buttocks. The SP responded by stating that AV1 struck the SP’s buttocks on purpose and said to AV1, “I know you want to fuck me.”

· Another time, they were talking about peanuts. AV1 asked the SP if s/he liked peanuts and the SP said, “I like nut in me.” AV1 believed the SP’s use of the word “nut” meant “semen,” as to say, “I like [semen] in me.” [Note: The word “semen” was used by AV1 to describe the incident and should not be used as an indicator of the gender and/or the genitalia of aV1 or the SP.]

· One time, AV1 was talking about a rapper and told the SP that the rapper was “cute.” The SP responded to AV1, “Wow. You’re cheating on me. You don’t want this [the SP’s genitals] no more?”

· One time, AV1 gave the SP a hug from behind and “accidentally” touched the SP’s breasts. AV1 stood there and was like, “What the hell” before pulling away from the hug. The SP did not say anything or pull away from AV1 during the hug.

· The SP also told AV1, “Guess what my favorite sex position is?” and “I know you think I’m hot.” The SP said that s/he wished AV1 was 18 years old and that the SP “would fuck [AV1] if [s/he] was 18.”

· Another youth (Y2) told AV1 that the SP said the same thing to Y2 about wishing Y2 was 18 years old. AV1 did not see this happen.

· Another youth (Y1) told AV1 that the SP “grabbed [Y1’s genitalia].” AV1 did not see this happen. Y1 told AV1 that one time, s/he was trying to dunk a basketball and accidentally touched the SP’s breast, and that the SP responded by saying to Y1, “That was fun. Do it again.” AV1 did not see this happen.

· AV1 got “super defensive over” the SP with other youth and felt “weird” that the SP might have said similar things to Y1 and Y2. The SP made AV1 feel “really special.” AV1 was “scared” to talk about the SP with the DHS investigator because the SP once told AV1, “Don’t snitch (on me). I will get in deep trouble.”

Video footage, that had no date or time stamp, of the facility’s youth bedroom area showed the SP sitting at a desk with a laptop in front of him/her on a table. AV1 walked behind the SP and wrapped his/her arms under the SP’s arms and around the SP’s torso so that both of AV1’s hands were on the front of the SP’s chest. AV1’s head was resting on the SP’s shoulder or touching the SP’s head. The SP did not appear to say anything or pull away from AV1. The SP remained still with his/her hands on the laptop. The contact lasted approximately 14 seconds before AV1 let go and walked away. At a later point in the same video, AV1 sat in a chair next to the SP and the two sat shoulder to shoulder (touching shoulders and upper arms) while the SP typed on the laptop.

The PSE provided the following information:

· On January 30, 2024, AV1 said that s/he “really, really needed” to speak to the PSE. They met, and AV1 told the PSE that s/he had a “special bond” with an unidentified staff person. AV1 said that s/he “felt guilty” that this staff person might get in trouble because of his/her relationship with AV1. AV1 said that they had “special conversations” and that the staff person “cared about [AV1] more than anyone else.” The PSE asked AV1 if any sexual boundaries were crossed and AV1 said, “We didn’t have sex, but” and then refused to say anymore.

· AV1 did not identify the staff person by name but told the PSE that the staff person was out on leave at that time. The PSE knew the “only staff” who was out on leave at the time was the SP.

· The PSE added that AV1 had a history of “exaggerating” and “attention seeking.” However, when AV1 spoke about the SP’s conduct, s/he appeared “sincere” and “upset.”

· On February 5, 2024, AV1 told the PSE that s/he was “scared” the SP might “retaliate” against AV1 because of what AV1 previously shared about the SP’s conduct. AV1 was “worried” that the SP “really liked [AV1]” and might try to touch AV1 “inappropriately.” The SP had previously made comments to AV1, like, “I want to fuck you,” “I want you to nut in me,” and “I want to have sex with you.” One time, the SP “suggestively rubbed [his/her own] breasts” in front of AV1. Another time, AV1 hugged the SP and “accidentally brushed [the SP’s] breast,” and the SP responded, “Yeah, I know you want me bad.”

P1, P2, and P3 provided the following information:

· P3 said that on January 15, 2024, s/he went to the gym to check-in with the youth. The SP was in the weight room with some of the youth. When P3 finished talking to the various youth, s/he left the gym, and the door closed behind him/her. However, s/he immediately turned back because s/he forgot to say goodbye to the SP. P3 reopened the gym door and saw the SP sitting on a gym mat with AV1 and Y1, who were sitting “incredibly close” to the SP. P3 told AV1, “Scootch away.” In response, AV1 stood up and got “mad at” P3. The SP “just sat there.” P3 left the gym and told P2.

· P2 said that s/he talked to the SP about allowing the youth to sit “too close” in the gym; “Almost sitting on [the SP’s] lap.” During this conversation, the SP “got argumentative” with P2 and said that the distance s/he was sitting from the youth was “not a big deal, I don’t mind it.”

· P1 said that on January 20, 2024, s/he walked into the gym and saw the SP sitting on a gym mat on the floor with AV1 lying next to him/her with his/her head resting on the SP’s thigh. P1 told them, “Boundaries,” and the SP responded by saying, “[AV1’s first name] is fine.” P1 did not say anything further because s/he did not want to start an argument with AV1 present.

· P2 and P3 each said that following P1’s observations in the gym on January 20, 2024, AV1 appeared “dysregulated” in the living room and wanted to speak privately to the SP. However, it was suppertime, and the SP was supposed to be in the cafeteria supervising youth. P2 told the SP to go to the cafeteria, six or seven times, and each time, the SP refused. Then another supervisor arrived, who “firmly” told the SP to go to the cafeteria. The SP was “very visibly disgusted” but did leave to the cafeteria. AV1 walked with the SP to the cafeteria.

· P1 and P3 each, separately, asked AV1 about the incident in the gym on January 20, 2024. AV1 provided consistent information to P1 and P3 that while AV1 had his/her head on the SP’s thigh, the SP said, “I hope it doesn’t stink down there,” which AV1 believed was referring to the SP’s genitals. AV1 told P3 that this made him/her uncomfortable. AV1 also told P3 that the SP wished AV1 was the SP’s boy/girlfriend and wanted AV1 to “nut” the SP. One time, the SP told AV1, something like, “We can’t date. I wish you were 18.” AV1 told P3 that the SP showed him/her pictures of “a stripper’s profile” on the SP’s cellphone.

· P3 said that on January 21, 2024, another youth (Y3) mentioned that the SP and AV1 were hugging in the bedroom area. This prompted P3 to review the camera footage. P3 said that staff were not allowed to hug a youth or sit next to a youth. Y1 told P3 that the SP showed him/her “a stripper profile” and pictures of the SP at a “strip club” on the SP’s cellphone. Y2 told him/her that one time on the gym mat, s/he put his/her leg over the SP’s leg. This was all Y2 had shared about his/her interactions with the SP. Y2 did not want to talk about it further.

FM1 said that AV1 told him/her there was an unidentified staff who made comments about wishing AV1 was 18.

The SP provided the following information:

· At times, AV1 sat “too close” to the SP or said “things (to the SP) that [AV1] should not,” like that the SP was “cute” and that AV1 had a dream about having sex with the SP. When this occurred, the SP told AV1 to stop saying or thinking such things.

· Regarding the hug as seen on camera footage, the SP said that AV1 wanted a hug and walked up behind and hugged the SP. The SP told the DHS investigator, “I don’t know what the big deal was.” Staff could give “half hugs” to youth or a “full on hug” if there was another staff person present. AV1 gave the SP a “full on” hug, not a half-hug. There were no other staff present. The SP did not tell AV1 to stop the hug at that time. The SP planned to talk to AV1 later and tell him/her not to hug staff. However, allegations were raised about the SP’s conduct with AV1, and the SP never got the chance to talk to AV1 about the hug.

· The SP said that AV1 never rested his/her head on the SP’s thigh but did put his/her head on the SP’s shoulder at least once. The SP denied saying anything to AV1 about the smell of the SP’s crotch and denied showing AV1 pictures of a stripper.

· One time, the SP told AV1 that s/he wished AV1 was 18 years old. The SP was “embarrassed” for saying this and only said it to not “hurt [AV1’s] feelings.” The SP had no intention of dating AV1 and did not want a relationship with AV1.

· The SP believed the allegations were made because “some youth were trying to get [the SP] fired.”

· The SP was trained to not cross boundaries with youth.

Note: The SP was about ten years older than AV1.

Relevant Statute:

Minnesota Statutes section 609.341 defines “intimate parts” as including the primary genital area, groin, inner thigh, buttocks, or breast of a human being; and defined “sexual contact” as including the touching by the complainant of the actor's, the complainants, or another's intimate parts effected by a person in a current or recent position of authority. In any of the cases, this included the touching of the clothing covering the immediate area of the intimate parts.

Conclusion for Allegation One:

A. Maltreatment:

AV1 provided consistent information to the DHS investigator, P2, P3, and the PSE that the SP lay AV1’s head on the SP’s breast, allowed AV1 to lay his/her head on the SP’s upper thigh while making a comment regarding the smell of his/her genitals, and made comments more than one time about wanting to “fuck” AV1 and for AV1 to “nut” the SP. AV1 also stated that the SP showed AV1 and other youth a picture of a stripper, about his/her interactions with the stripper, and caressed his/her own breast in front of AV1. AV1 told the PSE that s/he had a “special bond” and “special conversations” with the SP, which made AV1 feel “guilty.” The PSE believed AV1 appeared “sincere” and “upset.” P1-P3 each saw the SP interacting with AV1 in a manner that included sitting “incredibly close,” laying AV1’s head on the SP’s upper thigh, and becoming “argumentative” when his/her conduct was questioned by other staff. Y1-Y3 also provided information about similar incidents with the SP’s conduct.

The SP said that s/he redirected AV1 when AV1 sat to close to him/her or commented to the SP about AV1’s dreams. The SP denied that AV1 lay his/her head on the SP’s thigh, denied commenting about the smell of his/her genitals, and denied showing AV1 a picture of a stripper. The SP also said s/he was trained to not cross boundaries with youth.

Video footage showed AV1 hugging the SP from behind with his/her arms under the SP’s arms, around the SP’s torso, so that both of AV1’s hands were on the front of the SP’s chest. The hug lasted for about 14 seconds with AV1 eventually letting go and without the SP stopping or addressing the behavior.

Regarding AV1 touching the SP’s “breast,” it was unclear if this was accidental as described by AV1. However, given that AV1 provided consistent information about the SP’s sexualized statements or conduct to more than one person and that others saw conduct consistent with AV1’s information, it was determined that the account provided by AV1 was more credible than the SP’s accounts.

Regarding sexual abuse:

AV1 was 15 years old at the time and living at the facility seeking help with his/her diagnoses, emotional regulation, and family reunification. The SP was about ten years older than AV1. Given the information provided by AV1, FM1, Y1-Y3, and P1-P3, there was a preponderance of the evidence that the SP’s conduct included statements and overt acts that represented a substantial risk of sexual abuse to AV1 and/or included the touching of intimate parts.

It was determined that sexual abuse occurred (the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 - 609.3451 [criminal sexual contact in the first through fifth degree]).

Regarding neglect:

Given AV1’s age and that s/he had diagnoses that would reasonably be expected to require some level of continued supports and services throughout his/her life, the SP’s interactions with AV1 likely hindered AV1’s ability to have a consistent understanding of the parameters of a therapeutic relationship, which could interfere with other individuals’ attempts to provide him/her with therapeutic services, both now and in the future. Therefore, there was a preponderance of the evidence the SP’s interactions with AV1 were detrimental to AV1’s ongoing mental health and were a failure to supply necessary care and to protect from conditions that seriously endanger AV1's physical or mental health when reasonably able to do so.

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

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

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

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

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

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

The SP received training on the facility’s Boundaries, Red Flags, and Professionalism, and on the Reporting of Maltreatment of Minors Act.

The SP was responsible for maltreatment of AV1.

C. Recurring and/or Serious Maltreatment: See Allegation Two.

Allegation Two: It was reported that the SP slapped AV2’s mouth causing him/her to have a swollen lip.

At the time of the incident, AV2 was 12 years old, and his/her diagnoses included attention-deficit hyperactivity disorder and disruptive mood disorder. AV2 wanted to work on emotional regulation and family reunification.

AV2 said that one day, the SP was “playing” or “horseplaying around,” and put his/her hand over AV2’s mouth. It did not feel like a slap. “It wasn’t a slap” but a “tap” “into a shove” but, which caused AV2 to bite his/her upper lip. AV2’s upper lip was pushed into his/her tooth and there was a “cut” inside his/her mouth. “I think [the SP] was doing it to play around, but to me, I did not like that.” When AV2 went to tell someone about it, the SP called AV2, “a snitch.” As the day went on, the SP “antagonized” AV2 and later when another youth “mocked” AV2, the SP “laughed.” Then “the whole program ganged up on” AV2 for “snitching on” the SP.

P1 said that s/he saw the SP “pop” or “smack” AV2’s mouth. The SP then laughed and said s/he was “joking around.” AV1 and Y1 were present and also laughed. When AV2 walked away, the SP stated that AV2 was going to do what s/he “does best,” which was “snitch.” AV2 later told P1 that the SP was “joking around” with AV1 and Y1, and “popped” AV2’s mouth for “no reason.” According to P1’s incident report, the day was January 20, 2024.

P2 said that Y1 told him/her that s/he saw the SP “pop” AV2’s mouth. P2 asked other unidentified youth about the incident, and some said the SP was joking around and some said the SP was not joking. “But all had in common that [the SP] did put [his/her] hand on [AV2] and [AV2’s] mouth whether it was aggressive or not aggressive is unclear.” There was no video footage of the incident. P2 added that regardless of the circumstances, staff should not put their hands on a youth. “We don’t horseplay with youth.” P2 asked the SP about the incident and the SP said that they were “horseplaying.” The SP told P2 that s/he was “not being mean,” but did put his/her hand on AV2’s mouth. The SP denied slapping AV2’s mouth.

The facility’s Incident Report and Review, written by P2, stated that AV2 “possibly bit [his/her] lip.” There was no medical response to the incident and/or injury recorded by P2.

The SP said that s/he and AV2 were “messing around,” during which, AV2 put his/her hand over the SP’s mouth and the SP did the same thing to AV2 in return. The SP covered AV2’s mouth with the SP’s hand. AV2 responded by “laughing about it.” “We went on about our day … Not a huge issue until now.” When AV2 told another staff about what happened, the SP did not call him/her “a snitch,” but did say, “Great. I am in trouble. Thanks.” The SP said that s/he did not slap AV2’s face.

FM2 did not have concerns or additional information relating to this incident.

Information maintained by the Department of Human Services (Report Number 2023000825) showed that on June 16, 2023, it was determined that the SP was responsible for physical abuse. On January 24, 2023, after a three-year-old child hit the SP in the face, the SP slapped AV1 in the face causing a “red” or “pinkish” mark. It was a single incident and although the SP stated that the mark lasted a “couple of days,” the child’s family member stated the mark was gone the next day so it was not determined whether the mark left was tissue damage or transitory in nature. The decision was not appealed.

Conclusion for Allegation Two:

A. Maltreatment:

AV2 said that the SP “tapped” his/her mouth while joking around, which caused AV2 to bite his/her upper lip; “It wasn’t a slap but a slap into a shove … more of a tap than a slap.” P1 saw the SP “pop” or “smack” AV2’s mouth. P2 said that Y1 told him/her that the SP “popped” AV2’s mouth and some said the SP was joking around and some said the SP was not joking. AV2 and P2 also provided information about the SP calling AV2 “a snitch” for talking about the incident.

The SP said that s/he was “horseplaying” and put his/her hand on AV2’s mouth. The SP denied slapping AV2’s mouth and denied calling AV1 “a snitch.” The SP’s conduct was inconsistent with the facility’s boundary and professionalism policies and procedures, which stated that horseplaying was not allowed.

Regarding physical abuse:

Although the SP’s actions were described as joking or horseplaying, touching a child on the mouth that was described as slapping/slapping into a shove/tapping/popping in a manner such that the child bites themselves, is not accidental. Therefore, there was a preponderance of the evidence that the SP’s actions caused injury to AV2 and represented a risk of physical injury.

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

Regarding neglect:

AV2 was 12 years old at the time and living at the facility seeking help relating to his/her diagnoses. The SP put his/her hands on AV2’s face and caused AV2 to bite his/her lip. When AV2 went to tell someone about the SP’s conduct, the SP’s reaction included calling AV2 “a snitch” in front of other youth, allowing other youth to “mock” AV2, laughing at AV2, and prompting the “whole program to gang up on” AV2. The SP’s conduct was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services.

Given AV2’s age and that s/he had diagnoses that would reasonably be expected to require some level of continued supports and services throughout his/her life, the SP’s interactions with AV2 likely hindered AV2’s ability to have a consistent understanding of the parameters of a therapeutic relationship, which could interfere with other individuals’ attempts to provide him/her with therapeutic services, both now and in the future. Therefore, there was a preponderance of the evidence the SP’s interactions with AV2 a failure to supply AV2’s with necessary care and a failure to protect AV2 from conditions that seriously endanger his/her physical or mental health when reasonably able to do so.

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

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

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

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

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

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

The SP received training on the facility’s Boundaries, Red Flags, and Professionalism, and on the Reporting of Maltreatment of Minors Act.

The SP was responsible for maltreatment of AV2.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated maltreatment for which the SP was responsible in this report was recurring and serious. The SP was responsible for sexual abuse and neglect of AV1 and physical abuse, resulting in injury, and neglect of AV2.

The SP was disqualified from providing direct contact services.

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

Action Taken by Facility:

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

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

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

Certification:

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

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


state: MN

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

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

Report Number: 202411084

Date Issued: March 5, 2025

Name and Address of Facility Investigated:

Nexus Mille Lacs Family Healing
407 130th Ave S
Onamia, MN 56359

Disposition: Maltreatment determined as to neglect of the alleged victim by the staff person.

License Number and Program Type:

1036935-CRF (Children’s Residential Facility)

Investigator(s):

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

651-431-6616

Suspected Maltreatment Reported:

It was reported that a staff person (SP) used a vaping device that contained tetrahydrocannabinol (THC) on a community outing and permitted an alleged victim (AV) to use the device. THC was the primary compound in marijuana that made users feel “high.”

Date of Incident(s): December 27, 2024

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on January 15, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (the P and the SP). The AV declined an interview with this investigator, but s/he provided information to the P, and in the Internal Review, and it was included below.

The facility provided services to youths ages 10-18 that focused on treating the whole child, not a single issue. There was a school on the facility grounds to meet each student’s individual needs and vocational opportunities were available for youths to learn job skills while giving back to the community.

Facility documentation including the AV’s Individualized Treatment Plan, showed that the AV was diagnosed with polysubstance dependence that was in remission, depression, and attention deficit hyperactivity disorder. The AV’s Admission Interview at the facility showed that s/he had a history of substance (including marijuana) use, and the Individual Guidance Plan showed that the AV wanted staff persons to help him/her stay positive and stay sober. The Intake Diagnostic Assessment Update documented that the AV was to refrain from using all mood-altering substances including alcohol, marijuana, and other “drugs” unless they were prescribed to him/her. The AV was loyal and had a great sense of humor.

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

· The VA declined an interview with this investigator, but in the facility’s Internal Review and/or in conversations with the P, the AV provided information that on a December 27, 2024, community outing, s/he took a hit from the SP’s vaping device and was aware that the device contained THC. The AV knew that s/he made a poor choice and thought that s/he would be given a “consequence” for not following his/her plans. According to the Internal Review, the facility observed and assessed the AV after the incident to determine any lasting effects of consuming THC, but there were no concerns, and the AV resumed his/her typical schedule.

· The P said that on the date of the incident, s/he, the SP, additional unspecified staff persons, the AV, and several other youths went ice fishing on a community lake. Staff persons drove facility vans to the outing, and after the youths and staff persons returned from the outing, the P learned that some of the youths said that the SP permitted the AV to use his/her vaping device on the outing. Since the SP had previously been honest with the P, the P directly asked the SP whether s/he permitted the AV to use the device, and the SP told the P that s/he did.

· It was foggy on the lake, and the P and the other youths did not see the AV or the SP using the vaping device, but they might have used the device while walking from one ice fishing hole to another. According to the P, the SP told him/her that the AV took one hit from the vaping device and then asked for a second hit, but the SP declined to let the AV use the vaping device again. Staff persons were not to use vaping devices in the facility, on facility grounds, in facility vehicles or drive facility vehicles after having vaped, or while on community outings. However, some staff persons likely brought their vaping devices to the facility and used them in their personal vehicles. Prior to this incident, the P had no concerns with the SP’s work.

· The SP said that in the weeks prior to the incident, s/he frequently thought of personal matters which caused him/her to feel anxious and distracted. The SP had nicotine and THC vaping devices in his/her personal vehicle, and s/he used the vaping device that contained THC for anxiety. The devices were small and could be completely concealed in the palm of one’s hand, so it would be difficult to know whether someone was using the vaping devices due to their size, and difficult to see vapor/smoke from the devices if it was foggy, or cold since the vapor/smoke might look like someone’s warm breath on a cold day.

· On the date of the incident, the SP took his/her personal coats and cold weather gear from his/her vehicle to the outing in case the youths on the outing forgot theirs or were cold. At the lake, the AV realized that s/he did not bring a coat, so the SP took off his/her personal coat that s/he was wearing and gave it to the AV to wear, because the SP wore multiple layers and was warm enough without the coat. The SP had used the THC vaping device earlier that day and both devices were in the SP’s coat pockets, but s/he did not think about that when s/he gave the coat to the AV to wear. The SP thought that the AV either saw him/her use the device or smelled the scent of the device on his/her coat and looked for it in the coat. When the AV found the device/s, s/he asked the SP to let him/her use the device/s and the SP agreed. The AV “hit” one of the devices, but the SP was unsure which device the AV used, and then gave the devices to the SP. The AV continued to ask the SP to let him/her use the devices again, but the SP realized his/her mistake, and declined to let the AV use them.

· When the SP, the P, the AV, and the other youths returned to the facility, the SP talked with the P and told him/her that s/he let the AV use a vaping device and would accept any repercussions from his/her actions. In hindsight, the SP should not have let the AV use the coat with vaping devices in the pockets, but the AV was cold, did not have a coat with him/her, additional coats the AV might have used were with the P at another location on the lake, and the SP forgot that the vaping devices were in the coat. The SP said that s/he did not read the youths’ plans of care because s/he wanted to treat the youths equally and did not want to treat them differently based on what s/he read in the plans. The SP did not know that the AV had a history of substance use.

The SP signed the facility’s Maintaining a Drug Free Workplace statement showing that s/he agreed to abide by the facility’s policies regarding substance use on August 26, 2024.

In Minnesota, persons under the age of 21 were prohibited from using vaping devices.

The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident.

Conclusion:

A. Maltreatment:

The AV’s diagnoses included polysubstance dependence in remission, and s/he had a history of substance use, including marijuana. The AV wanted help from staff persons to stay sober and was to refrain from using mood altering substances.

The AV declined an interview with this investigator, but s/he provided information to the P and/or in the Internal Review that on a community outing on December 27, 2024, the SP let the AV use a vaping device which contained THC.

The SP said that s/he was anxious and distracted leading up to the incident and used the vaping device with THC for anxiety but did not think about the vaping devices being in his/her coat when s/he let the AV wear the coat. The AV found the vaping devices in the SP’s coat and asked the SP to let him/her use them. The SP agreed and the AV used one of the devices, but the SP was unsure which one, then asked to use the devices again, but the SP declined and obtained the devices from the AV.

The SP realized his/her mistake and talked with the SP about it. In hindsight, the SP would have removed the vaping devices from the coat before letting the AV wear it.

Although the AV did not appear to be harmed by using vaping device/s, given that the SP said s/he permitted the AV to use vaping devices/s, that the AV was under 21 years of age, and that the AV’s diagnoses included polysubstance dependence and s/he had a history of substance use, there was a preponderance of the evidence that there was a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so.

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

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

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

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

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

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

The SP permitted the AV to use his/her personal vaping device/s, but s/he agreed to abide by the facility’s Maintaining a Drug Dree Workplace statement on August 26, 2024, and was trained on the Maltreatment of Minors Act prior to the incident. The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The neglect was not recurring because it was a single incident, and was not serious because the AV did not sustain a known injury from the incident.

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

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but not followed. At the time this report was written, the SP was no longer employed at the facility.

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

The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.

Certification:

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

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

doc_type: Maltreatment Finding


raw_content:
August 15, 2024

Michelle Murray, Authorized Agent

Nexus Mille Lacs Family Healing

505 Highway 169 N Ste. 500

Plymouth, MN 55441

License Number: 1036935 (CRF)

Report Number: 202403288, 202403379, 202403986

CORRECTION ORDER

Dear Michelle Murray,

On May 21, through May 24, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Nexus Mille Lacs Family Healing located at 407 130th Ave South, Onamia, MN 56359. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, and mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, and restrictive techniques standards under Minnesota Rules, part 2960.0710. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

PRACTICES

1. Violation: There was no documentation of a mental health professional providing weekly face-to-face clinical supervision to all staff providing program services for the following weeks:

a. March 5, 2024 (programs 3 and 4);

b. March 6, 2024 (program 1); and

c. March 20, 2024 (program 1).

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

2. Violation: One of thirteen grievances did not meet requirements. A grievance dated January 22, 2024, did not include investigation findings and resulting action taken by the license holder.

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

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

PERSONNEL FILES

3. Violation: Seven of seven personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways:

a. Staff did not receive the following orientation training before having unsupervised contact with residents:

i. Emergency procedures (personnel file numbered 14);

ii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents (personnel file numbered 14);

iii. General and special needs, including disability needs, of residents and families served (personnel files numbered 7 and 9 through 14);

iv. Data practices regulations and issues (personnel files numbered 11 and 13);

b. Staff did not receive the following orientation training prior to having direct contact with youth:

i. Concepts of trauma-informed care and how to provide services to each youth according to those concepts (personnel files numbered 7 and 13);

ii. Culturally competent care (personnel file numbered 7);

iii. Racial bias and racism issues (personnel file numbered 7);

iv. Health related disabilities (personnel files numbered 7 and 9 through 14)

c. Staff did not receive orientation training on the license holders program abuse prevention plan within 72 hours of first providing direct contact services (personnel files numbered 7, 13 and 14); and

d. Staff did not receive orientation training on the programs rules of conduct and policies and procedures related to the discipline of residents served during the first 45 days of employment (personnel files numbered 13 and 14).

Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3 and 245A.65, subdivision 3 and Minnesota Rules, part 2960.0100, subpart 3, item A and 2960.0150, subpart 4, item C and 2960.0650, subpart 1, item E.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

4. Violation: Nine of nine personnel files reviewed for requirements governing ongoing training did not meet requirements. Staff did not receive the following training on an annual basis:

a. Vulnerable adult maltreatment reporting for calendar year (CY) 2022 (personnel files numbered 1, 2 and 4) and CY 2023 (personnel file numbered 14);

b. The license holders program abuse prevention plan for CY 2022 (personnel files numbered 2 through 6, 8, and 14) and CY 2023 (personnel file numbered 14);

c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 through 6, 8, 13, and 14);

Statute and Rule Violated: Minnesota Statues, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subdivision 14 and 2960.0100, subpart 3, item A.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating personnel numbered 14 has received program abuse prevention plan training, and submit documentation demonstrating that all staff have been trained on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services.

RESIDENT FILES

5. Violation: Three of four resident files reviewed for requirements governing resident information did not meet requirements (resident files numbered 1, 2, and 4). There was no documentation in the youth’s file that the license holder recorded and maintained the contact information for all known biological family members and fictive kin of the youth.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (g).

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

6. Violation: One of four resident files reviewed for requirements governing admission criteria did not meet requirements (resident file numbered 4). There was no documentation that before or at admission, the license holder examined the placement agency’s information about the resident to determine and document the following:

a. Whether the program can meet the residents needs;

b. Whether the resident is a danger to the resident’s self or others; and

c. Whether the program is able to meet the resident’s cultural, emotional, educational, mental health and physical needs.

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

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

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

a. The license holder did not communicate verbally and in writing to a resident who is capable of understanding the facility’s rules and details of the due process system used in the facility (resident file numbered 2); and

b. There was no documentation to demonstrate the that license holder had provided youth with a written copy of the resident’s basic rights information within 24 hours of admission (resident file numbered 4).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 4.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

8. Violation: One resident file reviewed for requirements governing vulnerable adult orientation did not meet requirements (resident file numbered 1). The license holder did not orient a vulnerable adult, within 24 hours of admission to the program, or upon turning 18, to policies and procedures governing maltreatment of vulnerable adults and the internal and external reporting policies, including the telephone number for MAARC.

Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c).

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

9. Violation: One of four resident files reviewed for requirements governing admission screenings did not meet requirements (resident file numbered 2). The screenings did not indicate the degree to which the resident’s family desired to be involved during the resident’s stay at the facility.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

10. Violation: One of four resident files reviewed for requirements governing program services did not meet requirements (resident file numbered 1). There was no documentation that the license holder reviewed the emergency plan with the resident at least once every six months.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

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

a. The individual treatment plan (ITP) was not completed within 10 working days of admission (resident file numbered 3);

b. The ITP did not include the following required components, when psychotropic medications were administered (resident files numbered 2 and 3):

i. Description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate; and

ii. Data collection methods the license holder would use to monitor and measure changes in the symptoms and behaviors that were to be alleviated by the psychotropic medication.

Rule Violated: Minnesota Rules, part 2960.0600 and 2960.0620, subpart 1, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

11. Violation: Two of three resident files reviewed for requirements governing service plan reviews did not meet requirements in the following ways:

a. There was no documentation that the interdisciplinary team reviewed and evaluated the IAPP as part of the service plan review, using the individual assessment and any reports of abuse relating to the resident (resident file numbered 1); and

b. The license holder did not review the resident’s case and treatment plans on a monthly basis for March, 2024 (resident file numbered 3).

Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 2960.0180, subpart 2, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

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

a. The license holder did not document attempts to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident file numbered 4); and

b. There was no documentation that the license holder provided a resident who is 18 years of age or older their prescription medication upon discharge (resident file numbered 1).

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

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

13. Violation: Two of three resident files reviewed for requirements governing the use of psychotropic medication did not meet requirements (resident files numbered 2 and 3). The license holder did not document the following:

a. Monitoring for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication;

b. Monthly psychotropic medication review; and

c. Data collected since the last review.

Rule Violated: Minnesota Rules, part 2960.0620 subpart 2 and subpart 5, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

14. Violation: Two of three resident files reviewed for requirements governing informed consent for psychotropic medications did not meet requirements (resident files numbered 1 and 2). The informed consent did not include how risks and side effects of the psychotropic medication would be managed.

Rule Violated: Minnesota Rules, part 2960.0620, subpart 7, item E.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

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

a. Staff did not contact the mental health professional or the facility’s program director to inform them about the use of the physical hold within 30 minutes after initiating the physical hold on June 25, 2023, and July 21, 2023 (resident file numbered 4);

b. The staff person who implemented the emergency use of physical holding did not document it’s use immediately after the incident concluded on the following dates:

i. November 29, 2022 (resident file numbered 1);

ii. April 21, 2024 and April 27, 2024 (resident file numbered 2);

iii. June 25, 2023, July 21, 2023, and August 21, 2023 (resident file numbered 4);

iv. May 17, 2022, May 25, 2022 and June 16, 2022 (resident file numbered 5);

v. January 23, 2024, January 24, 2024 and January 31, 2024 (resident file numbered 3);

c. The time the physical hold began and the time the resident was released was not documented for incidents dated June 25, 2023, and July 21, 2023 (resident file numbered 4); and

d. The resident’s behavioral change and change in physical status that resulted from the use of the procedure was not documented on January 31, 2024 (resident file numbered 3)

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items E, G, and K.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

16. Violation: One of five resident files reviewed for requirements governing the administrative review of restrictive procedures did not meet requirements (resident file numbered 4). The administrative reviews did not indicate whether the procedure was used in accordance with the resident’s treatment plan for incidents dated June 25, 2023, and July 21, 2023.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 10, item B.

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

17. Violation: One of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 3). The license holder did not provide the resident with a signed receipt of their personal property inventory upon discharge.

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

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

18. Violation: Two of three resident files reviewed for requirements governing transition services plans did not meet requirements in the following ways:

a. The plan did not consider the environment into which the resident would return and recommend how the resident may deal with issues and potential challenges within that environment (resident file numbered 4);

b. The plan was not developed with input from the resident (resident file numbered 4);

c. A copy of the plan was not provided to the resident (resident files numbered 1 and 4); and

d. The contents of the transition services plan did not contain treatment needs (resident file numbered 4).

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021.

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

19. Violation: Two of three resident files reviewed for requirements governing aftercare services did not meet requirements (resident files numbered 1 and 4). The program did not provide discharge planning and family-based aftercare support to the youth for at least six months after the youth’s discharge from the program.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (i).

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

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

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

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

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

ATTN: Maddy Gilbertson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Questions

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

Sincerely,

Maddy Gilbertson, 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


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

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

Report Number: 202308021

Date Issued: July 10, 2024

Name and Address of Facility Investigated:

Nexus Mille Lacs Family Healing
407 130th Ave. S.
Onamia, MN 56359

Disposition: Maltreatment determined as to

neglect of an alleged victim by a staff person.

License Number and Program Type:

1036935-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
gessner.rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that a staff person (SP) brought a bag to work which contained two vapes, one of which contained tetrahydrocannabinol (THC). An alleged victim (AV) took the vapes from the bag and later reported feeling “weird;” the AV tested positive for THC.

Date of Incident(s): September 17, 2023

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 28, 2023; from documentation at the facility and through four interviews conducted with two facility staff persons (P1 and SP), the AV, and the AV’s guardian (G).

According to the AV’s Individualized Treatment Plan, the AV was diagnosed with conduct disorder, generalized anxiety disorder, major depressive disorder, and attention-deficit disorder. At the time of the incident, the AV was 13 years old. The AV liked to play sports, such as baseball and football, and liked to read.

The SP provided the following information:

· On September 17, 2023, the SP carried a fanny pack into the facility in which the SP had two vape pens. The SP took off her/his fanny pack and placed it on a bench to play basketball with some residents. Afterwards, the SP noticed the zipper was open, so the SP checked and noticed the vape pens were missing. One vape contained nicotine and the other contained THC extract.

· The SP asked other staff persons if anyone saw someone touch her/his fanny pack and residents were asked and pockets searched but the vapes were not found. The SP informed P1 but did not mention that one of the vapes had THC because s/he was worried about getting into trouble.

· The SP was aware of the facility’s policy on smoking and tobacco which included vapes, however, the SP regularly brought his/her vape into the facility.

· The SP was notified that s/he was “suspended,” and that the AV had taken the vapes and tested positive for THC. The SP was retrained on the policy and stated s/he no longer brings such items into the facility.

Th AV provided the following information:

· On an unspecified date the AV noticed that a vape had fallen out of the SP’s pocket, but the SP picked it up right away. On September 17, 2023, other residents were playing basketball, on the way to the bathroom, the AV noticed that the SP’s fanny pack had fallen off a bench; the AV took the vapes that were in the SP’s fanny pack.

· The AV did not know one of the vapes had THC, but it smelled like marijuana. The AV had never tried marijuana before. The AV used the THC vape about three times before it was taken by staff persons. The AV said the THC made her/him feel “goofy” like when you “get up too fast and you feel dizzy.”

P1, a supervisory staff person provided the following information:

· The SP called P1 on Sunday September 17, 2023, and learned that the SP had lost two vapes within the facility but was not informed that one of the vapes contained THC. Residents were checked but the two vapes were not found that day. One day later another staff person saw the AV with one of the vapes; the AV turned it over but claimed s/he did not have the other one. The THC vape was still unaccounted for. P1 learned that the SP had been worried that the second vape had not been found because it contained THC.

· Two days later P1 was informed that the bathroom smelled “minty,” and that the AV had just been in the bathroom. P1 talked with the AV again but s/he denied having the vape. The AV was taken to nursing where s/he was searched and the second vape was found hidden in the AV’s waistband.

· A drug test was administered to the AV, who tested positive for THC. The AV stated s/he “had no idea but [s/he] took a hit, [s/he] felt kind of weird.” The AV also stated that “it was scary because [s/he] had never been high before.” The AV mentioned that s/he had used the THC vape pen for two days but did not share it with anyone else at the facility.

· The AV also stated that s/he had shared the other vape pen with another resident, but that resident denied using it. The other resident was also tested for THC but was negative.

· P1 noticed that the SP always carried a fanny pack. Staff persons have consistently been told that they cannot bring vapes into the building; they must leave vapes in their cars and can use them in designated areas.

The G stated that s/he was aware of the incident involving the vape but did not know that one of the vapes contained THC. Prior to the incident, the G did not have any other concerns about the facility.

The facility’s Smoking/Tobacco policy stated that “smoking or the use of tobacco or “tobacco-like” products is not permitted” in any facility. Tobacco-like products was defined to include any delivery systems such as e-cigarettes. Staff persons were allowed to use such products in designated outdoor smoking areas. Facility staff persons were to keep tobacco within their vehicle or the back office and not within residents’ access. Facility staff persons were prohibited from providing the tobacco products to residents.

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

Facility records showed that the SP was trained on the Reporting of Maltreatment of Minors Act, the AV’s care plans, and the facility’s Smoking/Tobacco policy.

Conclusion:

A. Maltreatment:

On September 17, 2023, against policy, the SP brought two vapes in a fanny pack into the facility, the SP set the fanny pack down to play basketball with some residents. The AV knew the SP carried vapes, as s/he had seen the SP with vapes before. The AV picked up the SP’s fanny pack and took the two vapes contained inside. When the SP picked up her/his fanny pack, s/he noticed the vapes were missing and notified other staff persons, including P1 but did not disclose that one of the vapes contained THC.

That the SP was not allowed to bring vape pens into the facility but had regularly done so prior to the incident, the AV knew that the SP carried vapes so took them from the SP’s fanny pack and used them including the one which contained THC which made the AV sick. Later, the AV tested positive for THC.

Given that the AV was able to obtain two vapes one which contained THC, an illegal substance for the AV, because the SP brought the vapes into the facility, and that the AV used the THC vape and tested positive for THC there was a preponderance of the evidence that there was a failure to provide the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable able to do so.

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

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

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

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

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

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

The SP was responsible for the care of the AV. The SP was trained on the facility’s Tobacco/Smoking policy and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible did not meet the statutory criteria to be determined as recurring or serious because it was a single incident, and the AV did not sustain an injury requiring the care of a physician.

The SP was not disqualified from providing direct contact services.

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

Action Taken by Facility:

The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. The facility did not identify a need to retrain staff persons. However, the SP noted that s/he was retrained on policies.

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

The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.

Certification:

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

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