raw_content:
August 12, 2022

CERTIFIED MAIL

Jon Benson, Authorized Agent

On-Belay House

115 Forestview LN N

Plymouth, MN 55441

License Number: 800099

ORDER OF CONDITIONAL LICENSE

Dear Jon Benson:

The Department of Humans Services (DHS) is placing your license to provide Chemical Health Children’s Residential Treatment services (CRF) at 115 Forestview LN N, Plymouth, MN 55441 on conditional status for two years, beginning August 25, 2022. This order is based on your noncompliance with Children’s Residential Facility (CRF) licensing requirements. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

On June 6 through 8, 2022, DHS licensors conducted a licensing review at your facility located at 115 Forestview Lane North, Plymouth, Minnesota, 55441. As a result of this licensing review, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, citing 33 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of children served by the program.

Nature and Severity:

o Failure to comply with background study requirements (violation numbered 1 through 2);

o Failure to ensure the staff met required qualifications (violation numbered 3 and 4);

o Failure to comply with discipline policy and procedure requirements (violation numbered 5);

o Failure to comply with staffing ratio’s (violation numbered 6);

o Failure to ensure the environment provides for the comfort, privacy, and dignity of residents and that it is kept in good repair and housekeeping and maintenance is operated on a consistent and healthy basis (violation numbered 7);

o Failure to comply with health services requirements (citation number 8);

o Failure to comply with maltreatment of vulnerable adults and minors reporting policies and procedures (violation numbered 9 through 11);

o Failure to comply with staff orientation and annual training requirements (violation numbered 12 to 16);

o Failure to comply with weekly supervision of an individual with a temporary permit from the Board of Behavioral Health and Therapy (violation numbered 17); and

o Failure to comply with requirements for transition and discharging a resident (violation numbered 18 and 19).

Chronicity: Your program received its license on February 4, 1980. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes the last four years:

o Sixteen of the 33 violations are repeat violations similar to violations cited in the licensing review correction order June 16, 2020.

o One of the 33 violations are repeat violations similar to violations cited in the Background Study fine order May 19, 2020.

o Eight of the 33 violations are repeat violations similar to violations cited in the licensing review correction order March 6, 2018.

Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of children served in your care, your license to provide Children’s Residential Facility services is placed on a conditional status.

Licensing Violations

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

1. Violation: As a result of a licensing review, a DHS licensor determined that 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 for.

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

Repeat Violation: In a Correction Order that DHS issued on May 19, 2020, you were previously found in violation of this same statute.

2. Violation: The license holder operates multiple licensed programs and failed to affiliate staff persons on all active background study rosters for programs that the staff persons were working in.

a. A background study was submitted for SP6, SP8, SP11, SP12, and SP17 under license number 1038850; however, the staff persons identified were also working under license number 800099; and

b. A background study was submitted for SP15 under license number 800098; however, the staff person identified was also working under license number 800099.

Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f).

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute.

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.

Rule Violated: Minnesota Rules, part 2960.0460, subpart 3.

4. 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).

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

5. 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.

Rule/Statute Violated: Minnesota Statutes 245A.04, subdivision 14, paragraph (a) and, and 2960.0080, subparts 4, items A, and 5, A.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute.

6. 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.

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

7. 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.

Rule Violated: Minnesota Rules, parts 2960.0110, subparts 2 and 3, items A and D, and 2960.0200, item A.

8. 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 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).

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

9. 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

Statute and Rule Violated: Minnesota Statues, 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.

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

· June 16, 2020

· March 6, 2018

10. Violation: The license holder’s internal reviews 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.

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

11. 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.

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

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

· June 16, 2020

· March 6, 2018

12. 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).

Statute and Rule Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245A.19, paragraph (a), and Minnesota Rules, parts 2960.0460, subpart 8, item A, 2960.0100, subpart 3, item A, and 2960.0070, subpart 5.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute.

13. 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.

Rule Violated: Minnesota Rules, part 2960.0100, subpart 5

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

· June 16, 2020

· March 6, 2018

14. 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.

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

b. The license holders program abuse prevention plans; and

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

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

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute.

15. 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.

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

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute.

16. Violation: Four of four personnel files reviewed for requirements governing in-service training hours did not meet requirements in the following ways:

a. The full-time staff did not complete at least 24 hours of training for calendar year 2021 (SP2 and SP6); and

b. The part-time direct care staff did not have at least one hour of training per fifty hours worked for calendar year 2021 (SP3 and SP5).

Rule Violated: Minnesota Rules, part 2960.0150, subpart 4, items B and D.

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute.

17. Violation: One personnel file reviewed for requirements governing supervision of an individual with a temporary permit (SP1) did not meet requirements. The file did not contain documentation that the staff person received supervision related to clinical practices at least weekly by an LADC for the weeks of April 18, 2022, May 16, 2022, May 23, 2022, and May 30, 2022.

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

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute.

18. 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.

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

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

· June 16, 2020

· March 6, 2018

19. 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).

Rule Violated: Minnesota Rules 2960.0190, subparts 1, items A and B, and 2, items A and B.

20. 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.

Rule Violated: Minnesota Rules 2960.0160, subpart 2, C.

21. Violation: Three of four resident files reviewed for requirements governing the inventory of personal property did not meet requirements.

a. The inventory only contained one staff signature and no resident signature, therefore the license holder did not sign the inventory upon admission by two staff if the resident refused to sign (R1 and R5);

b. The inventory was not signed by the license holder or the resident upon admission (R2); and

c. The discharge inventory was not signed by the license holder or the resident (R5).

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

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

· June 16, 2020

· March 6, 2018

22. Violation: One of two resident files for persons eighteen and older was reviewed for requirements governing the assessment of risk and development and review of the individual abuse prevention plan (IAPP) and did not meet requirements. The IAPP was not reviewed during each service plan review from creation to discharge (R6).

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

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

· June 16, 2020

· March 6, 2018

23. Violation: Two of four resident files reviewed for requirements governing the initial services plan (ISP) (R1 and R3) did not meet requirements. The ISP did not include the issues that are to be addressed in the first treatment sessions.

Rule Violated: Minnesota Rules, part 2960.0485.

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

a. The health screening did not include the most recent physician and clinic name, address and telephone number (R1 and R2); and

b. No documentation of a mental health screen completed within six working days of admission (R1 through R3, and R5).

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

25. 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).

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

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

· June 16, 2020

· March 6, 2018

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

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

27. Violation: The license holder failed to provide therapeutic recreation treatment services that are led by, directed by, or provided according to a plan developed by a qualified alcohol and drug counselor.

Rule Violated: Minnesota Rules, part 2960.0450, subpart 2, item D.

28. Violation: The license holder did not develop an annual training plan for employees that was relevant to the population being served.

Rule Violated: Minnesota Rules part 2960.0150, subpart 4.

29. Violation: A review of incident reports for November 2021, December 2021, and June 2021 identified the following incidents met the definition of a critical incident and were not reported to the commissioner of human services as required:

a. An incident occurred on November 30, 2021 involving a resident running from the program and returned by police transport on December 1, 2021; and

b. An incident occurred on June 20, 2021 involving the fire department responding to a call and clearance of the building.

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

30. Violation: The license holder failed to provide a written response to grievances within five business days of receipt and document the findings and actions taken by the license holder as required. A review of grievances submitted from September 2020 to May 2022 did not include the following:

a. A grievance dated January 30, 2021 did not document the findings and actions taken by the license holder; and

b. Grievances dated April 30, 2021 (x3), May 2, 8, and 28, 2021, did not contain a response nor was there documentation of the findings and actions taken by the license holder.

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

31. 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.

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

32. Violation: The outcome measures, evaluations and community advising did not meet requirements in the following ways:

a. The license holder did not complete an annual evaluation of the programs strengths and weaknesses in calendar year 2020 and 2021 using the following performance indicators:

1) Accidents;

2) The use of restrictive procedures;

3) Grievances;

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

5) Information from the programs outcomes and outcome measures;

6) Results of resident and family satisfaction surveys; and

7) Critical incidents; and

b. The license holder did not meet annually with their board of directors or advisory committee nor with the community leaders representing the area where the facility is located for calendar years 2020 and 2021. The license holder reported meeting with the local police department, though did not provide documentation of those meeting notes.

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

Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute.

33. Violation: The license holders plan for transfer of clients and records upon closure did not meet requirements. The license holder did not have a plan for transfer of clients and records upon closure; therefore, the controlling individual did not annually review and sign the plan for transfer of clients and records upon closure for calendar year 2021.

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

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

· June 16, 2020

· March 6, 2018

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

Immediate corrective action required

You must immediately correct the violations cited above. Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license.

CONDITIONAL LICENSE TERMS

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.

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

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

· Supply information that is accurate or more complete

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

· Be made before the deadlines provided below

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Licensing Division

Attention: Legal Unit

PO Box 64242

St. Paul, MN 55164-0242

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

Commissioner, Department of Human Services

Office of Inspector General

Licensing Division

Attention: Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Conditional license stayed pending reconsideration

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

Legal authority for this licensing action

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

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

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

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

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

Questions

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

Sincerely,

Paula Halverson, Unit Manager

Licensing Division

Office of Inspector General

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


state: MN

facility_name: Passageways

raw_content:
April 16, 2025

Beth Holger, Authorized Agent The Link

1210 Glenwood Ave.

Minneapolis, MN 55405 License Number: 1074613 (CRF)

CORRECTION ORDER

Dear Beth Holger:

On February 24-26, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Passageways, located at  . This review 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. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Practices

1. Violation: The license holder did not maintain compliance with applicable health rules. A certified food manager was not employed between 11/27/2024 and 2/26/2025.

Rule Violated: Minnesota Rules, part 2960.0120, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure to meet all applicable health rules.

2. Violation: The plan for transfer of clients and records upon closure was not signed by a controlling individual for calendar years 2023 and 2024.

Statute Violated: Minnesota Statute, section 245A.04, subdivision 15a, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Statute.

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

3. Violation: The program abuse prevention plan was not reviewed annually by the license holder’s governing body for calendar years 2023 and 2024.

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

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

4. Violation: Four of fourteen incident reports reviewed for requirements governing critical incident reporting did not meet the requirements. The following incidents were not reported as critical incidents as required:

a. One incident requiring response by law enforcement and transport via ambulance dated 6/17/24; and

b. Three incidents requiring response by law enforcement dated 8/13/24, 9/7/24 and 9/7/24.

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

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

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

Personnel

5. Violation: One of two personnel files reviewed for orientation did not meet requirements (personnel file numbered 1). Documentation of training did not include:

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

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

c. Concepts of trauma-informed care and how to provide services to each youth according to those concepts; and

d. Impact of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences.

Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h), and Minnesota Rules, part 2960.0100, subpart 3, item A

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staff orientation meets requirements. Within 30 days receipt of this order, provide training and submit documentation for personnel file numbered 1 to demonstrate compliance.

6. Violation: Two of two personnel files did not meet the requirements for ongoing training.

a. There was no documentation of ongoing annual training in the maltreatment of minors reporting requirements for calendar year 2024 (personnel file numbered 1);

b. The emergency plan was not reviewed at least every six months for calendar years 2023 and 2024 (personnel files numbered 1 and 3);

c. Annual training was missing for concepts of trauma informed care and how to provide services according to these concepts for calendar year 2023(personnel files 1 and 3);

d. Annual training was missing for impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma for 2023 (personnel files 1 and 3).

Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 3, paragraph (h), and 245A.66, subdivision 4; and Minnesota Rules, part 2960.0080, subpart 14.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing staff training meets requirements. Within 30 days of this order, provide training and submit documentation for personnel files numbered 1 and 3 to demonstrate compliance.

Resident Files

7. Violation: Three of three resident files did not meet requirements governing resident information (resident files numbered 1, 2 and 3). Documentation did not include the resident’s time of admission.

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

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

8. Violation: Three of three resident files did not meet requirements governing shelter admissions (resident files numbered 1, 2 and 3). The resident file did not include the following:

a. An assessment of the resident’s vulnerability to maltreatment;

b. An assessment of the resident’s immediate needs.

Rule Violated: Minnesota Rules, part 2960.0520, subparts 2, items A and B; and 3

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that requirements governing shelter admissions meets all applicable requirements. Within 30 days receipt of this order, submit the following for one resident to demonstrate compliance:

· An assessment of a resident’s vulnerability to maltreatment;

· A plan to reduce the risk of maltreatment;

· An assessment of a resident’s immediate needs; and

· A plan for meeting a resident’s immediate needs.

9. Violation: Three of three resident files did not meet requirements governing admission procedures.

a. The inventory of the resident’s property was not signed by both the resident and staff (resident files numbered 1 and 2); and

b. The license holder did not provide documentation of informing resident’s parent, guardian or custodian within a reasonable time that resident’s basic rights information is available (resident files numbered 1, 2 and 3).

Rules Violated: Minnesota Rules, part 2960.0070, subpart 4; and 2960.0050, subpart 3, item B.

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

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

10. Violation: Two of three resident files did not meet requirements governing health care in the following ways:

a. The license holder did not provide documentation that a newly admitted resident’s licensed prescribing medical person had been contacted to obtain the following (resident file numbered 3):

i. Instructions for administering prescribed medication;

ii. Symptoms the medication will alleviate; and

iii. Symptoms that would warrant consultation with the physician;

b. The license holder did not provide documentation indicating parental or guardian consent to administer prescribed medications (resident file numbered 1); and

c. The license holder did not provide documentation of the quantity of medication initially received from the pharmacy (resident files numbered 1 and 3).

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

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

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

11. Violation: One of two resident files did not meet requirements governing discharge procedures. The license holder did not document the return of the resident’s property with a signed receipt upon discharge (resident file numbered 1).

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

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of this same Rule.

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

12. Violation: Two of two resident files did not meet requirements governing shelter discharge. The license holder did not document the name and address of the party to whom the resident was released following discharge when the resident had been in shelter for more than ten days (resident files numbered 1 and 2).

Rule Violated: Minnesota Rules, part 2960.0520, subpart 2, item C.

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of the same Rule.

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

13. Violation: Two of two resident files did not meet requirements governing transition services plan. The license holder did not document that a copy of the transitional services plan was given to the resident or to the facility where the resident was placed(resident files numbered 1 and 2).

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

Repeat Violation: In a Correction Order that DHS issued on Sept. 13, 2021, you were previously found in violation of the same Rule.

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

Written Response Required

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

Submissions required as part of the corrective action ordered must be sent to your licensor by email at Laura.Huff1@state.mn.us or by mail:

Commissioner, Department of Human Services ATTN: Laura Huff

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:

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 - Licensing 444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-4234 or at Laura.Huff1@state.mn.us.

Sincerely,

Laura Huff, Licensor Licensing Division

Office of Inspector General

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

doc_type: Correction Order


facility_name: Prairie Lakes Youth Programs- Integrity House South

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: 202302651

Date Issued: July 19, 2023

Name and Address of Facility Investigated:

Prairie Lakes Youth Programs - Captain's Academy
1804 Civic Center Drive
Willmar, MN 56201

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

License Number and Program Type:

1056393-CRF (Children’s Residential Facility/Department of Corrections)

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 rolling chair to push an alleged victim (AV) and pin him/her against a wall, which bruised the AV’s left side.

Date of Incident(s): March 22, 2023

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a):

"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 April 17, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1 and the SP), and the AV.

The facility provided residential services to adolescents though the use of individualized programs that might incorporate the use of addiction recovery, truancy support, and pet, individual, group, and family therapies. The length of stay for each youth and the supports offered to him/her were based on the needs and age of the youth and tailored to his/her needs. There were video cameras at the facility that recorded many of the facility’s common areas. The incident between the SP and the AV was video recorded.

The AV resided in a non-secure residential program at the facility when the incident occurred. Attention deficit hyperactivity disorder and anxiety were included in the AV’s diagnoses, and s/he was admitted to the facility in the fall of 2022. The AV was active and liked to stay busy.

Interviews with this investigator, facility documentation, and a video recording from the facility provided the following information regarding the incident:

The AV said that on March 22, 2023, s/he walked behind a desk at which the SP was seated in a common area of the facility and picked up a dry erase marker then walked away from the desk. The SP asked the AV for the marker, but the AV declined. The SP then rolled his/her chair into the AV, pushing the AV into a wall behind the desk. The AV was upset and knocked a printer off the desk then left the area. Later the AV observed that s/he had a bruise on his/her left side that s/he thought was from being pushed into the wall.

A copy of the video recording obtained by this investigator showed that at 7:43 p.m., on March 22, 2023, the AV, several youths, the SP, and another staff person (P2), were in a common area on the facility. The SP was seated in a rolling chair behind an L-shaped desk with his/her back toward the wall behind the desk. One end of the desk was against wall but there was an opening between the other end and the wall behind the desk that allowed staff persons to walk behind the desk and sit in the rolling chair. There was a dry erase board on a wall behind the desk on which staff persons wrote assignments for the youths. P2 was seated to the left of the L shaped desk at a small table with his/her back toward the SP, who was seated behind the desk at the time of the incident.

The recording showed the AV walk toward the desk, look at the dry erase board, and walk behind the desk. The SP was seated behind the desk and rolled backward in the chair to block the AV, then spoke with him/her. The SP gestured toward the opening between the desk and the wall, but the AV walked around the SP to the dry erase board, then erased information written near the top of the board. The SP remained seated in the chair, spoke with the AV, and then rolled forward toward the desk. The AV walked behind the SP to exit the desk area, and then the SP pushed his/her chair backward into the AV’s right side, which pushed the AV’s left side into the wall. The AV immediately pushed the SP’s chair forward toward the desk and the AV and SP gestured toward each other and talked. The AV pointed his/her finger at the SP, stood over the SP, and knocked a piece of office equipment from the desktop onto the floor, then exited the room. During the incident, P2 remained seated at the table, and at some point, looked over his/her right shoulder toward the AV and the SP. The incident lasted about one minute and showed that the AV was not pinned against the wall.

The SP said that on the date of the incident, the AV was dysregulated and went behind the desk to erase the dry erase board, so s/he “stepped up” to prevent the AV from erasing it, but the AV wiped everything down, then started to take all the markers. The SP said that s/he was seated in the chair and tried to move it out of the AV’s way because s/he thought that the AV was going to walk in front of him/her. However, the AV continued behind the SP, who was not “100 % sure” whether his/her chair made contact with the AV. P2 was also present when the incident occurred, but might not have seen the incident because s/he was completing documentation and his/her back was to the SP and the AV. It was a “violation” for the AV to go behind the desk and “technically” the SP could have “put [his/her] hands on” the AV to remove him/her, but the SP was never comfortable putting his/her hands on anyone. The incident happened quickly according to the SP and his/her actions were not malicious. The SP was unaware that the AV sustained a bruise during the incident.

P1, a supervisory staff person, said s/he learned of the incident a couple of days after it occurred when the AV told him/her about it. P1 assessed the AV for injuries and observed a bruise on the AV’s left side which was at a location on the AV’s body that was consistent with an injury the AV might have sustained, based on his/her description of the incident and the video recording. P1 reviewed the video recording of the incident and talked with the other youths who were present when it occurred. The youths’ accounts of the incident varied and might have been affected by their previous interactions with the AV and SP. P1 thought that the video showed a power struggle between the AV and the SP, and that the SP took the AV’s actions personally instead of walking away from the AV or switching out with another staff person. The AV might be difficult to redirect and there had been numerous conversations with staff persons about successful interventions to use with the AV. There were no previous concerns regarding the SP’s work, but s/he might be impatient or “unsympathetic” with the youths.

The facility’s Restrictive Procedures Policy was reviewed. However, using a chair to block, push, or pin a youth was not an approved technique described in the policy.

Facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and the facility’s Restrictive Procedures Policy prior to the incident.

Conclusion:

A. Maltreatment:

The AV said that on March 22, 2023, the SP pushed him/her into a wall with the SP’s chair, which caused a bruise on the AV’s left side. The AV told P1 about the incident. P1 watched a video of the incident from the video recording system at the facility and gave this investigator a copy of the recording.

The video recording showed the AV walking behind the SP who was seated in a rolling chair at a desk in a common area. The AV erased information on a dry erase board then walked behind the SP again. The SP pushed his/her chair backward into the AV, which pushed the AV into the wall behind the desk. The AV then pushed the SP’s chair forward and there was a conversation between the SP and AV which included gestures.

The SP stated that the AV was dysregulated on the date of the incident and violated the facility’s expectations for the youths by going behind the desk. The SP moved his/her chair and attempted to prevent the AV from taking markers out of the area. However, the SP was unsure whether the chair made contact with the AV and was unaware that the AV sustained an injury during the incident. The SP said that his/her actions were not malicious.

P1 stated that the AV had a bruise on his/her left side that was consistent with injuries that might result from being pushed into the wall. The video showed a power struggle between the AV and the SP according to P1, which might have been avoided if the SP walked away from the AV or switched out with another staff person.

Using a chair to block or push a youth was not an approved technique in the facility’s Restrictive Procedures Policy.

Although the SP said that his/her actions were not malicious and the AV should not have been behind the desk, given that the video recording showed the SP push his/her chair into the AV which pushed him/her into the wall but did not pin him/her, that P1 saw the AV’s bruise and said that it was consistent with an injury that might result from being pushed into the wall, and that the SP would have reason to minimize his/her actions, there was a preponderance of the evidence that the SP’s actions were not accidental and caused injury to the AV.

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).

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.

Facility documentation showed that the SP was trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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 physical abuse for which the SP was responsible was not recurring because it was a single incident but was serious maltreatment because it resulted in a bruise on the AV’s side that was visible a couple of days after the incident.

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 which determined that its policies and procedures were adequate but were not followed. The SP was suspended after P1 became aware of the incident and his/her employment with the facility was ended after P1 viewed the video recording of the incident.

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.

Because this facility was licensed by the Department of Corrections, a copy of this report was provided to them.

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


facility_name: PrairieCare Residential Services

report_date: October 17, 2025

raw_content:
October 17, 2025

Todd Archbold, Authorized Agent

PrairieCare Residential Services

12915 63rd Avenue North

Maple Grove, MN 55369

License Number: 1082863

Investigation Report Number: 202504323

CORRECTION ORDER

Dear Todd Archbold,

On July 22 through the 25 of 2025, the Department of Human Services (DHS) conducted a licensing review and investigation at your facility, PrairieCare Residential Services, located at 12915 63rd Avenue North, Maple Grove, MN 55369. This review and investigation were conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, residential mental health treatment program for child certification standards under Minnesota Rules, parts 2960.0580 through 2960.0700, with a residential program certification as a qualified residential treatment program under Minnesota Statutes, section 245A.25. As a result of this visit, 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 VIOLATION

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

Policies and Practices

1. Violation: The license holder’s service delivery plan did not meet requirements. The plan did not describe how the program provides services according to the following ways:

a. That the following staff be available 24 hours a day and seven days a week to provide care within the scope of their practice:

i. A registered nurse or licensed practical nurse; and

ii. Other licensed clinical staff.

b. Contacting and facilitating outreach to each resident’s family members, including the resident’s siblings, and must document outreach to the resident’s family members in the resident’s file, including the contact method and each family member’s contact information;

c. Recording and maintaining the contact information for all known biological family members and fictive kin of the resident;

d. Documenting in the resident’s file how the program integrates family members into the treatment process for the resident, including after the resident’s discharge from the program, and how the program maintains the resident’s connections to the resident’s sibling;

e. Discharge planning and family-based aftercare support to each resident for at least six months after the resident’s discharge from the program; and

f. When providing aftercare to a resident, having monthly contact with the resident and the resident’s caregivers to promote the resident’s engagement in aftercare services and to regularly evaluate the family’s needs.

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

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

2. Violation: The license holder’s time-out policy did not include the following required components:

a. Time-outs must be used under the direction of a mental health professional, facility director, or the program manager;

b. The use of time-out must be consistent with the resident’s treatment plan;

c. The treatment team must include and document the review of the use of time-out for each resident during the review of the resident’s treatment plan;

d. Staff must document the use of time-out in the resident’s record and include the following information:

i. The factors or circumstances which caused the need for the use of time-out;

ii. The resident’s response to the time-out;

iii. The resident’s ability to de-escalate during the time-out procedure; and

iv. The resident’s ability to maintain acceptable behavior after the time-out.

Rule Violated: Minnesota Rule, part 2960.0080, subpart 5, item D.

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

3. Violation: The license holder’s restrictive procedure plan did not meet requirements. The plan did not include the following items:

a. A description of the training that staff who use restrictive procedures must have prior to staff implementing the emergency use of restrictive procedures;

b. A license or certification holder must not use a prone restraint on any person receiving services in a program, except if a person rolls into a prone position during the use of a restraint, the person must be restored to a nonprone position as quickly as possible; and

c. How the license holder will address and document contraindicated physical restraints.

Rules Violated: Minnesota Statutes, section 245A.211, subdivisions 3 and 4, and Minnesota Rules, part 2960.0710, subpart 2, item C and subpart 9

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

4. Violation: The license holders plan for transfer of records and clients upon closure did not meet requirements. The plan was not reviewed and signed annually by a controlling individual of the program for the year of 2025.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the plan for transfer of records and clients upon closure meets all applicable requirements.

5. Violation: The license holders provision of trauma informed care did not meet requirements. The license holder implemented “room-time” for all residents, where they were required to remain in their rooms for 30 to 60 minutes, three to four times per day. Through interviews with staff, it was determined that this practice was not modified to respond to the effects of trauma on the person receiving services, and did not acknowledge the effects of trauma on a person receiving services.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (d)

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

6. Violation: For two of two weeks reviewed, the license holder’s practice of clinical supervision did not meet requirements in the following ways:

a. For December 23 through 29, 2024, five of thirty-two staff who provided program services did not receive clinical supervision from a mental health professional; and

b. For July 7 through 13, 2025, nine of thirty-six staff who provided program services did not receive clinical supervision from a mental health professional.

Rule Violated: Minnesota Rules, part 2960.0630, subpart 2

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

Repeat Violation: License holder was cited for similar violations in a Correction Order dated April 8th, 2022.

Resident Files

7. Violation: Four of four resident files reviewed for requirements governing resident information did not meet requirements in the following ways:

a. Admission documentation regarding the following did not occur upon or within five working days after admission (resident file numbered 1):

i. Legal authority for a resident’s placement;

ii. Date and time of admission;

iii. Race or cultural heritage, language the resident speaks and write, tribal affiliation, if any;

iv. Description of presenting problems: including medical problems, circumstances leading to admission, mental health concerns, safety, concerns including assaultive behavior, victimization concerns;

v. 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

vi. spiritual or religious affiliation of the resident and the resident's family

b. The resident file did not have documentation demonstrating that the license holder recorded and maintained the contact information for all known biological family members and fictive kin of the resident (resident files numbered 1, 2, 3, and 4).

Rules Violated: Minnesota Rules, part 2960.0070, subpart 3 and Minnesota Statutes, section 245A.25, subdivision 4, paragraph (g)

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

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

a. When public funds were not used to pay for services, there was no documentation to demonstrate that the resident was screened by a mental health professional using a screening process that is equivalent to that required by Minnesota Statutes, section 245.4885, subdivision 1, before admission (resident files numbered 1); and

b. There was no documentation to demonstrate that the license holder determined their program could meet the developmental and mental health needs of the resident (resident files numbered 1, 2, 3, and 4).

Rule Violated: Minnesota Rules, part 2960.0670, subpart 2, items C and F

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

9. Violation: Four of four resident files reviewed for requirements governing admission procedures did not meet requirements (resident files numbered 1, 2, 3, and 4). Each resident was not provided with a complete description of the applicable programs and activities available to residents in the facility.

Rule Violated: Minnesota Rules, part 2960.0160, subpart 4, item B

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meet all appliable requirements. Within 30 days receipt of this order, submit a description of appliable programs and activities that demonstrates compliance.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

10. Violation: Four of four resident files reviewed for requirements governing admission screenings did not meet requirements (resident files numbered 1, 2, 3, and 4) in the following ways:

a. The sexually abusive behavior screening, vulnerability assessment, and cultural screening did not include all of the required components

b. Documentation about the degree to which the resident’s family desires to be involved during the residents stay at the facility did not include the family’s response.

c. There was no documentation to demonstrate a trauma-specific screening was completed.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items A through D, and Minnesota Statutes, section 245A.25, subdivision 3, paragraph (c)

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

11. Violation: Two of two resident files reviewed for requirements governing chemical health education did not meet requirements (resident files numbered 1 and 2). There was no documentation to demonstrate that the license holder provided education about chemical health to the residents who have had a problem related to inappropriate chemical use, but who do not have a sufficient chemical use history to refer to treatment.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 9, item D

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

12. Violation: Four of four resident files reviewed for requirements governing program services did not meet requirements in the following ways:

a. The license holder did not facilitate participation of the resident’s family members in their treatment program, consistent with their best interests (resident files numbered 1 and 2); and

b. The license holder did not contact and facilitate outreach to each resident’s family members, including the resident’s siblings, and document outreach to the resident’s family members in the resident’s file, including contact method and each family member’s contact information (resident files numbered 1, 2, 3, and 4).

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

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

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

a. The individual treatment plan was not completed within 10 working days of admission (resident files numbered 1, 2, and 4);

b. The plan did not identify a schedule for accomplishing treatment goals and objectives (resident files numbered 1 and 2);

c. The use of psychotropic medication was not included in the resident’s individual treatment plan (resident files numbered 2);

d. The plan did not include a description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident files numbered 3 and 4); and

e. A mental health professional did not document involvement in the treatment planning process by signing the individual treatment plan (resident file numbered 1).

Rule Violated: Minnesota Rules, parts 2960.0600, item A; 2960.0620, subpart 1, items A and B; and 2960.0630, subpart 3, item B

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

14. Violation: Two of four resident files reviewed for requirements governing service plan reviews did not meet requirements (resident files numbered 1 and 4). There was no documentation to demonstrate the use of time-out for each resident was reviewed during the review of their treatment plan. in the following ways:

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 5, item D

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

15. Violation: One of four resident files reviewed for requirements governing health care did not meet requirements (resident file numbered 1). There was no documentation to demonstrate that the prescription medication belonging to the resident was given to the resident's parent or legal guardian upon the resident's release according to a pharmacy-approved plan.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item F

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

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

a. There was no documentation identifying a list of possible side effects for a resident prescribed a psychotropic medication (resident files numbered 1, 2, 3, and 4); and

b. The license holder did not document a psychotropic medication review at least monthly for the first six months (resident files numbered 1, 3, and 4).

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation involving psychotropic medications meet all appliable requirements.

17. Violation: Two of four resident files reviewed for requirements governing informed consent for the administration of psychotropic medication did not meet requirements in the following ways:

a. When oral consent was obtained, an explanation for why written informed could not be initially obtained was not documented. All psychotropic medications were listed on one informed consent form and the line for the explanation was left blank (resident files numbered 1 and 2); and

b. The license holder did not provide documentation demonstrating that they provide the required information in writing to the resident’s parents, the resident’s legal representative, and, to the extent possible, the resident (resident file numbered 1).

Rule Violated: Minnesota Rules, part 2960.0620, subpart 7

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

18. Violation: Two of two resident files reviewed for requirements governing time-out procedures did not meet requirements in the following ways:

a. The use of time out was not documented in the resident file (resident file numbered 1); and

b. Documentation of a time-out implemented on 04/02/2025 did not include the resident’s ability to de-escalate during the time-out or their response to the time-out (resident file numbered 4).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation for time-out procedures meet all appliable requirements.

19. Violation: One of three resident files reviewed for requirements governing restrictive procedures did not meet requirements (resident file numbered 5) in the following ways:

a. Documentation did not demonstrate that an immediate intervention was necessary to protect the resident or others from physical harm, for a physical hold implemented on 06/25/2025; and

b. Documentation did not demonstrate that the mental health professional was contacted to inform them about the use of physical holding and to ask for permission to use physical holding.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, item A and G

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation for restrictive procedures meet all appliable requirements.

20. Violation: One of two resident files reviewed for requirements governing no eject discharges did not meet requirements (resident file numbered 1) in the following ways:

a. Documentation did not demonstrate that the license holder conferred with other interested persons to review the issues involved in the decision, before discharging the resident who had not reached their treatment plan goals; and

b. Documentation did not identify whether any additional strategies could be developed to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation for no eject discharges meet all appliable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

21. Violation: Four of five resident files reviewed for requirements governing discharge did not meet requirements in the following ways:

a. There was no documentation to demonstrate that all of the resident’s personal property was returned to the resident (resident files numbered 1 and 4);

b. The transition services plan documentation did not demonstrate that the plan was developed with input from the resident’s family members (resident file numbered 6); and

c. The license holder did not document the extent to which the resident’s stay in the facility met the goals and objectives identified in the treatment plan (resident files numbered 3, 4, and 6).

Rule Violated: Minnesota Rules, parts 2960.0090, subpart 3, 2960.0190, subpart 1, item A, 2960.0140, subpart 2; and 2960.0190, subpart 2

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation for discharge procedures meet all appliable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 8th, 2022.

22. Violation: Three of four resident files reviewed for requirements governing aftercare did not meet requirements (resident files numbered 1, 3, and 4). There was no documentation to demonstrate family-based aftercare support was provided to the resident at least monthly.

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 meet all appliable requirements.

Personnel Files

23. Violation: Six of six personnel files reviewed for requirements governing ongoing training did not meet requirements (personnel files numbered 1, 2, 3, 4, 5, and 6) in the following ways:

a. For calendar year 2023, there was no documentation to demonstrate staff were trained on the impacts of culture, race, gender, and sexual orientation on individual resident’s behavioral health and experiences of trauma annually; and

b. The license holder did not document the name of the entity that provided the training.

Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h) and Minnesota Rules, part 2960.0100, subpart 5

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

Written Response Required

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

Submissions required as part of the corrective action ordered must be sent to your licensor by email (hannah.horsch@state.mn.us) or mail:

Commissioner, Department of Human Services

ATTN: Hannah Horsch

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

Legal authority for this licensing action

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

· This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960.

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

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-5909.

Sincerely,

Michael Cihla, 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/