report_date: September 27, 2024

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: 202403158

Date Issued: September 27, 2024

Name and Address of Facility Investigated:

Wings
1326 E Ripley
Litchfield, MN 55355

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

License Number and Program Type:

1047343-CRF (Children’s Residential Facility)

Investigator(s):

Van Mulheron
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6592

thu-van.mulheron@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) had inappropriate verbal and physical interactions with three alleged victims (AV1-AV3) that included:

· The SP told AV1 one time, “You have a nice rack.”

· AV2 was talking with another resident and said, “I like the way they spank me,” and the SP winked at AV2 and said, “I’m a little gun-shy,” and hit AV2’s buttocks with a piece of paper.

· The SP rubbed AV3’s back “intimately” and said to AV3, “You can rub your dirty hands all over me.”

Date of Incident(s): Prior to April 17, 2024

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on April 26, 2024; from documentation at the facility; and through 14 interviews conducted with two supervisory staff persons (P1 and P2), four staff persons (P3-P6), AV1-AV3, the SP, AV2’s family member (FM2), and AV3’s family member (FM3). Another youth and their family member were interviewed, but did not provide information pertinent to the allegations. Attempts were made to via telephone, mail, and/or email contact and interview AV1’s family member (FM1), another resident’s (R), and two staff persons (P7 and P8), but the attempts were unsuccessful. Information from multiple staff persons was that P7 was a supervisory staff person, however, P7’s personnel file documented s/he was a staff person.

The facility provided residential care for adolescents in need of out of home placement. The facility had separate gendered wings (G1 and G2) that had a common room in between. A staff bathroom and a laundry room were located next to the G1’s wing in the common room. Past the common room was a dining room used for meals provided to the residents. The dining room had a counter that separated the dining room and the kitchen.

P1-P6 and the SP provided consistent information that residents were spoken to with respect and courtesy and that staff persons were not allowed to touch residents and that there should be “bubble” between staff persons and residents.

The facility’s Treatment Rules for Staff stated that staff persons “are prohibited from touching clients in any way. Exceptions are only allowed in circumstances in which touch is necessary to preserves client’s safety.” The facility’s Ethics, Boundaries, and Professional policy stated, “Staff should safeguard a client’s physical, emotional, … wellbeing. Behaviors that could damage a clients wellbeing include but are not limited to; verbally attacking clients … and shaming or embarrassing clients.”

The facility’s personnel file showed that the P1-P8 and the SP were each trained on the facility’s Treatment Rules for Staff, Ethics, Boundaries, and Professional policy, and the Reporting of Maltreatment of Minors Act prior to the incidents.

Regarding AV1:

AV1’s Client Face Sheet stated AV1 was seventeen years old at the time of the incident and diagnosed with major depressive disorder, post-traumatic stress disorder, generalized anxiety disorder, cannabis use disorder, and alcohol use disorder. AV1’s Individual Treatment Plan stated that staff persons were to help AV1 develop effective coping skills to manage his/her substance abuse and mental health concerns. AV resided in G2.

AV1 provide the following consistent information to this investigator and in the facility’s internal review:

· AV1 moved into the facility on February 28, 2024. On an unknown date two to three weeks after, AV1 was in the dining room with the other residents for lunch. AV1 said that s/he was wearing a “tight but not a tight, tight” shirt and walked up “alone” to the lunch counter to grab his/her lunch. When AV1 reached the counter, the SP was standing there but AV1 did not speak with the SP. AV1 said that the SP “mimicked me” and was “walking with [his/her] chest poked out,” and said to AV1, “You have a big set there.”

· AV1 said that s/he “felt disgusted” by the SP’s comment due to “past stuff in my life that I went through.” The comment “was like a trigger … because someone said that to me before.” AV1 then walked back to a table but did not immediately tell anyone about the incident. Two days later, AV1 one spoke with P1 about the incident and a decision was made that AV1 would no longer have contact with the SP and that other staff persons would bring meals to AV1.

· AV1 said that at other times the SP would tell jokes that made him/her “uncomfortable” but AV1 would “ignore” the SP. AV1 was not able to recall what the jokes were. AV1 said that s/he had no concerns about other staff persons in the facility.

P3 said that on an unknown date during lunch time s/he was in the dining room with the SP. AV1 walked into the dining room and stood near a table. The SP looked at AV1, and then grabbed two pieces of fruit and held the fruit up to his/her chest and began to “prance” around the dining room looking directly at AV1. The SP did not make any comments to AV1 while doing this. AV1 told the SP that “it made [him/her] feel weird” but the SP ignored AV1 and continued to “prance” around the room. P3 said that AV1 was “so uncomfortable” that AV1 had staff persons get his/her food and would then ate facing away from the SP. P3 then told P7 about the SP’s actions.

P5 said s/he was not present during the incident, but a couple of days after the incident, AV1 told P5 that the SP had made a comment about chest and made a gesture regarding AV1’s chest which made AV1 “very upset.” P5 said that that the SP was then not at the facility for about a week and on a day after the SP returned to work, AV1 had a “panic attack.” AV1 was “screaming” and said, “Why is [the SP] even there?” AV1 told P5 s/he was “uncomfortable” so P5 took the AV to the front of the building to “get some air.” P5 said that it took two hours for AV1 to calm.

P2 said that on March 13, 2024, AV1 told him/her that the SP had made a comment “insinuating” AV1 had a big chest. Then on March 15, 2024, AV1 said that the SP told him/her, “Snitches get stitches.” P2 was not able to provide any more information about the incidents. P2 then told P1 about the incident. P2 did not speak with the SP but told P1 about the incident.

P1 provided consistent information to this investigator and in the facility’s internal review.

· P1 said that on March 13, 2024, P2 and P1 his/her concerns regarding the SP. AV1 said that the SP made a “suggestive” comment about AV1’s chest and “poked [his/her] chest out” at AV1 and said, “You have a big set.”

· On March 14, 2024, P1 met with AV1 to talk about the concerns and on March 15, 2024, AV1 told P1 that the SP said “snitches get stitches” to AV1. P1 spoke with AV1 and AV1 said that s/he did not want to see the SP “face to face.” P1 made a decision to allow staff persons to get AV1’s meals and bring them to AV1.

· On March 15, 2024, P1 spoke with the SP who denied the making the comments and gesture to AV1. P1 the spoke with the SP about the importance of being thoughtful in how they interact with residents and that it was not within the facility’s policy to make any sort of comments about resident’s looks or body. The SP then confirmed that s/he understood the facility’s expectations.

The SP provided the following information:

· On an unknown date during lunch, AV1 was at the lunch counter with other residents and said that s/he did not like the lunch that was made and wanted something else. The SP said, “No, that’s not part of our menu today.” The SP then offered alternative choices such as peanut butter and jelly sandwiches or fruit. AV1 and the other residents were “angered” and began to use “vulgar language.” The SP said that there were no other staff persons in the dining area at that time.

· The SP said that s/he was not aware of the allegation until P1 spoke with him/her. The SP “100%” denied saying to AV1, “You have a big set.” The SP said that those words were not in “[his/her] vocabulary.”

· The SP did say that “snitches get stitches” when s/he put chocolate chips in the pancakes for the residents in G1 and told them not to say anything to the residents in G2 because they did not get chocolate chips and as a “joke” said “snitches get stitches.”

The facility provided a log of concerns and conversations that P1 had with the SP that included on March 13, 2024, AV1 reported that the SP made a comment that insinuated s/he had big breasts. On March 15, 2024, the SP denied making any comments to AV1. The SP was placed on suspension until s/he accepted the condition of additional training for March 18, 2024. The SP declined the offer. On March 22, 2024, the SP called P1 and accepted the conditions of additional training and returned to work on March 23, 2024.

Regarding AV2:

AV2’s Client Face Sheet stated that AV2 was fifteen years old at the time of the incident and was diagnosed with major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, nicotine use disorder, and cannabis use disorder. AV2’s Individual Treatment Plan stated that staff persons were to help AV2 develop effective coping skills to manage his/her substance abuse and mental health concerns. AV2 resided in G1.

AV2 said that approximately two weeks prior to April 26, 2024, s/he was standing near the staff bathroom with other residents, P4, and the SP. AV2 asked the SP a questions about lunch and then turned to his/her peers and said “something stupid” s/he could not recall making the other residents laugh. The SP then “smacked [AV2’s] ass” with a piece of paper. AV2 turned to the SP and said “jokingly,” “Oh, [the SP’s name], I like when you do that.” AV2 then said, “I’m sorry.” The SP replied back, “It’s okay, I was just a little bit gun-shy,” and winked at AV2, which made AV2 feel “uncomfortable.” AV2 thought the SP meant “something sexually” by the comment. AV2 then walked away from the SP. P4, who was nearby, came over to AV2 and asked him/her what the SP said and AV2 told P4 what happened. AV2 did not tell P1 about the incident.

FM2 said that s/he was not aware of any “concerns” regarding AV2 and had no concerns about the facility.

P4 said that on an unknown date s/he was standing near the staff bathroom, next to AV2, other residents, and the SP. AV2 had made a comment s/he “was not supposed to make” to the other residents (P4 could not recall what the comment was). The SP looked at AV2 and “winked” and said, “I’m a little gun-shy” to AV2 and then “smacked” AV2 on the “butt” with a piece of paper. P4 then told the SP, “You can’t do that” and then the SP “quickly ran” into the staff bathroom and locked the door. P4 said that AV2 started to “freak out” so P4 directed AV2 into the G1 wing. When P4 and AV2 entered the G1 wing AV2 said, “[S/he] can’t be fucking touching me like that,” and “[P4] you need to get rid of [him/her].” P4 helped AV2 calm and reported the incident to P7.

P3 said that on an unknown date s/he saw AV2, P4, and the SP standing next to the laundry room in the commons area as s/he stood on the opposite side of the commons room. The SP had a piece of paper in his/her hand and “slapped” AV2 on his/her “butt” and then walked away from AV2. P3 did hear any conversation between AV2 and the SP, but AV2 “froze” and then walked back into the G1 wing. P3 went to AV2 and asked AV2 if s/he was “okay.” AV2 replied that s/he wanted to talk with P1 but P1 was not at the facility at that time. P3 did not know if P1 was aware of the incident. P3 said s/he did not tell anyone about the incident because P4 told P7 who told P2.

AV1 was in the G2 wing when s/he saw the SP, AV2, and other residents near the staff bathroom, when the SP “slapped [AV2] on the butt with a piece of paper.” AV1 was not able to hear any conversation between the SP and AV2 and did not see AV2’s reaction to the incident.

P2 said that on April 10, 2024, P4 and P8 told P2 that they had heard the SP say, “I’m a little gun-shy” to residents after the residents made “inappropriate” jokes to each other about spanking. P2 did not get the names of the clients.

P1 stated s/he was not aware of the incident between the SP and AV2 prior to this investigation. Afterwards, P1 spoke with AV2 and AV2 provided P1 with information that was consistent with the information AV2 provided during his/her interview.

The facility’s internal review provided the following information: AV2 stated that the SP “tapped” his buttocks over his pants with a packet of papers. AV2 said that this occurred in the dining room in the presence of peers. AV2 stated that this made him feel uncomfortable. AV2 stated that SP did not engage in any previous or subsequent incidences of inappropriate touch.

The SP said that on an unknown date s/he was walking out of the staff bathroom with paper in his/her hand. As s/he was coming out a group of residents walked by and as the SP was trying to lock the bathroom door the paper in his/her hand “brushed” a client’s shoulder. The SP did not recall who the client was, and that s/he had not engaged on any conversation with them. The SP denied saying “I’m a little gun-shy,” and did not know what that statement meant. (Note: According to the Merriam-Webster dictionary the definition of “gun-shy” was “markedly distrustful, afraid, or cautious.”)

Regarding AV3:

AV3’s Client Face Sheet stated that AV3 was seventeen years old at the time of the incident and was diagnosed with major depressive disorder, general anxiety disorder, cannabis use disorder, opioid use disorder, and nicotine use disorder. AV3’s Individual Treatment Plan stated that staff persons were to help AV3 develop effective coping skills to manage his/her substance abuse and mental health concerns.

AV3 provided the following consistent information during his/her interview and in the facility’s internal review:

· AV3 said that on an unknown date near the end of March 2024, s/he was standing in the dining room with the R during lunch. The SP came up behind AV3, “rubbed [his/her] hand down [AV3’s] back” and then walked into the kitchen and stood by the counter. AV3 felt “really uncomfortable” and “awkward because it was unnecessary.” AV3 said that “[the SP] should not be touching me.” AV3 then walked to the counter to talk with the SP. AV3 said to the SP, “How would you like it if I did it to you?” The SP replied back, “You could rub your hands all over me.” AV3 said that s/he felt “disgusted” after the SP’s comment. AV3 said that s/he told P6 about the incident but did “not believe” P6 did “anything about.” AV3 later told P3 who notified P1 of the incident.

· AV3 said that the SP had made other comments that made AV3 “uncomfortable.” The SP had previously told AV3 that “[AV3] had beautiful eyes” and that “[AV3] should be a model.”

· AV3 said that the SP was not to “touch” the residents and only certain staff persons were allowed to “touch” residents but was unfamiliar with what “touches were allowed other than fist bumps.”

FM3 said that s/he had no prior concerns about the facility.

P3 said that on an unknown date, AV3 told P3 that the SP had “rubbed” his/her hands up and down AV3’s arm and back which made AV3 feel “uncomfortable.” AV3 said that s/he did not address the incident at the time because s/he was “too scared” but AV3 also told P7 about the incident. The next day P3 heard the SP say “[AV3] beautiful eyes come here” when it was time to grab lunch from the counter. P3 said s/he did not report the incident to his/her supervisor because AV3 told P7 and that AV3 did not mention the incident again to him/her.

P6 said that on an unknown date, AV3 told P6 that the SP had touched his/her “shoulder,” and was “hitting on [AV3],” which made AV3 “uncomfortable.” P6 did not know when the incidents occurred but directed AV3 to tell P1 if s/he wanted to and showed AV3 the “paperwork” to fill out if AV3 wanted to file a complaint P1. P6 was “unsure” if AV3 reported the incident to P1. P6 said s/he did not tell P1 or P2 about what AV3 said.

P2 said that on April 6, 2024, P7 told P2 that AV3 said that the SP was “rubbing [AV3’s] back” and said to AV3, “You could run your hands all over my body.” The SP also told AV3 “[s/he] had beautiful eyes” and that “[the SP] could stair into them all day long.” P2 reported the incident P1.

P1 said that on April 11, 2024, P2 told him/her what AV3 told P7. AV3 had not said anything about the SP prior to this. P1 did not talk to the SP because his/her employment was ending. P1 spoke with AV3 after the SP no longer worked at the facility and AV3 provided information to P1 that was consistent with the information AV3 provided during his/her interview.

The SP denied that s/he touched any resident on the back. The SP said that s/he was trained not to “touch” the residents and it was “just ridiculous” that s/he would ever say “rub your hands all over me.” (Note: The SP ended the interview prior to its completion) but provided information for the facility’s internal review. The SP denied the majority of the reports alleged by staff and residents but acknowledged the need to improve his/her boundaries with residents and limit his/her workplace actions to those listed on his/her job description.

P1 and P2 had prior concerns regarding the SP’s verbal interaction with residents. The SP was retrained on how to properly interact with residents and that the SP was to solely focus on his/her specific job duties which did not include being a direct supervisor of residents.

· The facility provided a log of concerns and conversations that P1 had with the SP that included on April 6, 2024, P7 reported that a resident from G1 told him/her that the SP said s/he had “beautiful eyes” and that “[s/he] could stare into them all day.” P7 also reported that the SP told the G1 resident that “s/he] could rub his dirty hands all over me” and that the G1 resident said that the SP was “rubbing [his/her] back.” P7 also reported that the SP entered the G1 wing, sat down, and interacted with the residents. (Note: P1 did not talk to the SP about this incident.)

Conclusion:

A. Maltreatment:

Regarding AV1:

AV1 said that on an unknown date prior to March 15, 2024, s/he was alone by the kitchen counter and when the SP “mimicked” him/her and was “walking with [his/her] chest poked out” and then told AV1 “You have a big set there.” The AV said that s/he “felt disgusted” due to “past stuff in my life that I went through” after the SP made his/her comment. P3 stated that on one occasion s/he was in the dining room with the SP when AV1 entered the dining room, the SP placed two pieces of fruit at his/her chest and “pranced” around dining room while looking at AV1.

P1 spoke with the SP and the SP denied that the incident happened. The SP acknowledged that s/he said “snitches get stitches” but that it was said as a “joke” referring to an incident where G2 residents received chocolate chips and the G1 residents did not.

Although the SP denied the allegations to P1 and during his/her interview, given that P3’s account of what s/he saw the SP do was similar to AV1’s account, and that the SP had reason to minimize his/her actions for fear of repercussions, there was a preponderance of the evidence that the SP engaged in the interaction with AV1 as described by P3 and AV1.

Regarding AV2:

AV2 said that on an unknown date two weeks prior to April 26, 2024, s/he was standing near the G1 with other residents, P4, and the SP. AV2 said “something stupid” to make his/her peers “laugh.” The SP then “smacked [AV2’s] ass” with a piece of paper. AV2 then turned to the SP and said in a “joking” way, “Oh, [SP], I like when you do that.” AV2 then said, “I’m sorry,” to the SP. The SP replied back, “It’s okay, I was just a little bit gun-shy,” and then winked at AV which made AV2 feel “uncomfortable.” P4 was near AV2 and heard the conversation between the SP and AV2. P4 told the SP, “You can’t do that,” and then the SP ran into the bathroom. P3 and AV1 saw the SP “slap” AV2 on his/her “butt” but neither heard the conversation. P3 said that AV2 then “froze” and then entered the G1 wing.

The SP denied saying, “I’m a little gun-shy,” but said that on an unknown date s/he was walking out of the staff bathroom with paper in his/her hand. As s/he was coming out a group of residents walked by and as the SP was trying to lock the bathroom door the paper in his/her hand “brushed” a client’s shoulder. The SP did not recall who the client was, and that s/he had not engaged on any conversation with them.

Although the SP denied the allegations during his/her interview, given that P4’s account of what s/he saw the SP do was consistent with AV2’s account, that AV1 and P3 also saw the SP “slap” AV2 on the buttocks, and that the SP had reason to minimize his/her actions for fear of repercussions, there as a preponderance of the evidence that the SP engaged in the interaction with AV2 as described by AV2, P4, P3, and AV1.

Regarding AV3:

AV3 said that on an unknown date near the end of March 2024, the SP came up behind AV3 and “rubbed [his/her] hand down [AV3’s] back” and then walked into the kitchen and stood by the counter. AV3 felt “really uncomfortable” with the interaction. AV3 then walked to the counter to talk with the SP and said to the SP, “How would you like it if I did it to you?” The SP replied back, “You could rub your hands all over me.” AV3 later told P3 and P6 consistent information about the incident. The day after that, P3 heard the SP say “[AV3] beautiful eyes come here” when it was time for lunch.

The SP denied that s/he touched any resident on the back and said that s/he was trained not to “touch” residents and that it was “ridiculous” that s/he would ever say “rub your hands all over me.”

Although the SP denied the allegations during his/her interview, the SP had reason to minimize his/her actions for fear of repercussions. In addition, AV3 provided similar information during his/her interview and to P3 and P6 regarding the SP’s interactions and the interaction was similar in nature to those described by AV1 and AV2. Therefore, it was more likely that the SP engaged in the interaction as described by AV3.

AV1, AV2, and AV3 were each at the facility for support regarding their substance abuse and mental health disorders. AV1’s, AV2’s, and AV3’s Individual Treatment Plans stated that staff persons were to help each develop effective coping skills to manage his/her substance abuse and mental health concerns, so it was reasonable that each would likely continue to need supports to develop and maintain the necessary life and social skills to maintain and build healthy relationships. The SP’s interactions with AV1, AV2, and A3, who were 17, 15, and 17 years old (respectively), likely hindered their ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to each both now and in the future.

Therefore, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with AV1, AV2, and AV3 were detrimental to their ongoing mental health, were a failure to supply necessary care, and a failure to protect them from conditions or actions that seriously endangered their mental health.

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

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

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

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order,

prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

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

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

The SP was trained on the Reporting of Maltreatment of Minors Act and the facility’s Treatment Rules for Staff, Ethics, Boundaries, and Professional policy. The SP was responsible for maltreatment of AV1-AV3.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible was not “recurring” or “serious” maltreatment. The SP’s interactions with AV2 and AV3 were single incidents so it was determined that the SP’s overall interactions with AV1, AV2, and AV3 represented a pattern of behavior and therefore a single incident, and AV1-AV3 did not require the care of a physician.

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

Action Taken by Facility:

The facility completed an internal review and determined that their policies and procedures were adequate but was not adequately followed by the SP. The SP no longer worked at the facility.

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

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

Certification:

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

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


state: MN

facility_name: Wings

raw_content:
June 18th, 2024

Wylie Boehmlehner, Authorized Agent

1326 East Ripley Street,

Litchfield, MN 55355

License Number: 1047343

Report Numbers: 202306482

202309219

CORRECTION ORDER

Dear Wylie Boehmlehner,

On April 24th, 25th, and 26th, 2024 the Department of Human Services (DHS) conducted a licensing review and investigation at your facility, Wings, located at 1326 E. Ripley St, Litchfield, MN 55355. 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, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220, chemical dependency treatment program certification standards under Minnesota Rules, parts 2960.0430 through 2960.0500. 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 VIOLATIONS

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

Policies and Practices

1. Violation: The license holder’s operational policies and procedures did not meet requirements in the following ways:

a. The license holder’s policy for a resident’s communication and visitation with others inside and outside of the facility, Call & Visitation Rules, did not include that the license holder will allow for parental visits at times that accommodate the parent’s schedule;

b. The license holder’s written staffing plan did not identify the staffing assignments of the program based on the needs of the residents and the features of the physical plant; and

c. The license holder’s written maintenance plan did not include procedures for detecting, reporting, and correcting building and equipment deterioration, safety hazards, and unsanitary conditions

Rule Violated: Minnesota Rules, parts 2960.0080, subpart 15, item B, 2960.0150, subpart 3, and 2960.0200, subpart C

Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure operational policies and procedures meet all applicable requirements. Within 30 days receipt of this order, submit a revised maintenance plan and a revised staffing plan that meet all applicable requirements to demonstrate compliance.

2. Violation: The license holder’s plan for transfer of clients and records upon closure did not meet the requirements as they did not retain a signed copy of the plan for calendar year 2023.

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

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

3. Violation: The license holder’s satisfaction surveys did not meet requirements. The survey did not address satisfaction with the support of family and community reintegration.

Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, Item A

Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of satisfaction survey’s meets all applicable requirements. Within 30 days receipt of this order, submit a revised survey that demonstrates compliance.

4. Violation: The license holder did not meet requirements governing staff ratios. Documentation did not demonstrate that at least one direct care staff was present for every twelve residents during awake hours for the following dates and months of 2023:

a. May 1, 8, 22, 23; and

b. June 5, 7, 9, 14, 23, and 26.

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

Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the documentation of minimum staff to resident ratios meets all applicable requirements. Within 30 days receipt of this order, submit documentation of staff ratios for one week that demonstrates compliance.

Personnel Files

5. Violation: One of two personnel files reviewed for requirements governing programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), did not meet requirements (personnel file numbered 5). There was no documentation to demonstrate the staff person received 8 hours of training in co-occurring disorders annually in 2022.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191

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

6. Violation: One personnel file reviewed for requirements governing staff qualification did not meet the requirements in the following ways (personnel file numbered 4):

a. There was no documentation to demonstrate the staff person had an additional 30 hours of classroom instruction in adolescent development; and

b. There was no documentation to demonstrate the staff person received the required weekly supervision by a licensed alcohol and drug counselor for February through April, 2024.

Rule Violated: Minnesota Rules, part 2960.0460, subpart 5, item B and part 2960.0460, subpart 6a, item A

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

7. Violation: Four of six personnel files reviewed for requirements governing orientation did not meet requirements in the following ways:

a. The specific medication assistance training provided by the registered nurse was not documented in the personnel record (personnel file numbered 2);

b. The staff person was not oriented to cultural diversity and gender sensitivity prior to providing direct contact services (personnel file numbered 2);

c. The staff person was not oriented to vulnerable adult maltreatment reporting and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services within 72 hours of first providing direct contact services (personnel files numbered 1, 2, 3, and 6); and

d. There was not documentation of the staff person’s competency in crisis intervention techniques consistent with the program’s protective procedures plan (personnel file numbered 3).

Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, Minnesota Rules, part 2960.0080, subpart 11, item D, part 2960.0100, subpart 3, item A, and part 2960.0460, subpart 8, item C

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022.

8. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet the requirements in the following ways:

a. The staff person’s training on vulnerable adult maltreatment reporting, the program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services was completed late in 2023 (personnel file numbered 4); and

b. The license holder did not document the name of the entity that provided the training as they documented the supervisor instead (personnel files numbered 4 and 5).

Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, Minnesota Rules, part 2960.0100, subparts 3, item A, and 5

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022.

Resident Files

9. Violation: One resident file reviewed for requirements governing the individual abuse prevention plan did not meet requirements (resident file numbered 4). The license holder did not identify referrals that were made when the vulnerable adult was susceptible to abuse outside the scope or control of the licensed service.

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

Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of the individual abuse prevention plan meets all applicable requirements.

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

a. The license holder did not obtain the placing agency’s case plan goals for the resident and did not document their efforts to do so (resident file numbered 3).

b. Documentation did not demonstrate that the license holder identified and shared important information about the resident’s behaviors with persons who were directly involved in the resident’s treatment plan nor that they received and responded to a parent/guardian’s request for a resident’s records (resident file numbered 8).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 3, items A, B, D, and F

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

11. Violation: One of three resident files reviewed for requirements governing required treatment services and documentation did not meet requirements (resident file numbered 3). Documentation did not demonstrate the resident received at least 15 hours of service per week for the week of May 29, 2023.

Rule Violated: Minnesota Rule, part 2960.0450, subpart 2

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

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

a. There was no documentation to demonstrate the license holder attempted to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident files numbered 3).

b. The license holder failed to ensure that the prescribing physician’s directions for monitoring medications used by a resident were followed (resident file numbered 8).

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

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

13. Violation: Two of two resident files reviewed for requirements governing time out procedures did not meet requirements in the following ways (resident files numbered 5 and 7):

a. Documentation did not identify to where the resident was escorted; and

b. There was no documentation to demonstrate that time-out was used under the direction of a mental health professional, the facility director, or the program manager.

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

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

14. Violation: One of three resident files reviewed for requirements governing no eject discharges did not meet requirements (resident file numbered 5) in the following ways:

a. There was no documentation to demonstrate the license holder conferred with other interested persons to review the issues involved in the decision to discharge the resident prior to the discharge;

b. There was no documentation to demonstrate if the license holder determined if they, the treatment team, or interested persons, could develop any additional strategies to resolve the issues leading to the discharge as they did not develop a plan; and

c. The license holder did not document the reason for the discharge being warranted and the alternatives considered or attempted.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 27th, 2022.

15. Violation: One of three resident files reviewed for requirements governing programs that offer services to individuals with co-occurring mental health and chemical dependency problems under Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c), did not meet requirements (resident file numbered 2). The diagnostic assessment was not completed within 10 days of admission.

Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (i), and 245A.191

Corrective Action Taken: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of co-occurring resident files 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 (michael.s.cihla@state.mn.us) or mail:

Commissioner, Department of Human Services

ATTN: Michael Cihla

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, Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


raw_content:
June 27, 2022

Mattie Baumgartner, Authorized Agent

Wings

1326 E Ripley

Litchfield, MN 55355

License Number: 1047343

CORRECTION ORDER

Dear Mattie:

On May 10 through 12, 2022, a licensing review of Wings, located at 1326 E Ripley, Litchfield MN 55355 was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities Minnesota Rules, 2960.0010 through 2960.0120, group residential services under Minnesota Rules 2960.0130 through 2960.0220 and chemical dependency treatment services under Minnesota Rules, 2960.0430 through 2960.0490 (Rule CRF). As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

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

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

Policy, Procedure, and Practices

1. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (c).

Violation: The license holder’s policy and procedure manual did not include an index or table of contents.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the policy and procedure manual includes an index or table of contents and meet all applicable requirements. Within 30 days receipt of this order, submit a revised policy and procedure manual to demonstrate compliance.

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

Violation: The written emergency plan did not include specific actions by staff and residents for the protection of all persons in the case of a natural disaster.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the written emergency plan meets all applicable requirements. Within 30 days receipt of this order, submit a written emergency plan that includes all required components to demonstrate compliance.

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

Violation: The no eject policy did not include that the review process would not exceed five working days.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the no eject policy meets all applicable requirements. Within 30 days receipt of this order, submit a revised no eject policy to demonstrate compliance.

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

Violation: The program abuse prevention plan was not annually reviewed by the license holders governing body or delegated representative in calendar year 2021.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan annual review meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

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

Violation: The maltreatment of minor’s internal reviews did not meet requirements in the following ways:

a. An internal review completed for an event that occurred on June 2, 2021, was not dated. Therefore, it could not be determined that the review was completed within 30 days; and

b. Internal reviews completed on April 15 and December 6, 2021 did not include an evaluation of whether the reported event is similar to past events with the children or the services involved and if there is a need for corrective action taken by the license holder to protect the health and safety of children in care.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the maltreatment of minor’s internal review meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

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

Violation: The license holder’s outcome measures and evaluation for calendar years 2021 and 2022 did not meet requirements. The license holder did not evaluate strengths and weaknesses of the program using the outcome and outcome measures identified in Minnesota Rules, part 2960.0060, subparts 1 and 2 as a basis to make improvements in the program.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the outcome measures and evaluation meets all applicable requirements. Within 30 days of receipt of this order, submit an updated outcome measure and evaluation for calendar year 2022 that includes all required performance indicators to demonstrate compliance.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

7. Citation: Minnesota Rules, part 2960.0080, subpart 4, items B and C.

Violation: The rules did not meet requirements in the following ways:

a. The rules did not identify the consequences that would be applied to modify unacceptable behavior; and

b. The circumstances that will result in the use of a time-out were not included in the rules policy and/or program handbook.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the rules meets all applicable requirements. Within 30 days from receipt of this order, submit revised rules and/or program handbooks that meets all applicable requirements to demonstrate compliance.

8. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D.

Violation: The discipline policy did not include the use of time-out as a nonemergency behavior management technique, and two time outs were implemented on August 5, 2020.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the discipline policy includes the use of time out and meets all applicable requirements. Within 30 days from receipt of this order, submit a revised discipline policy to demonstrate compliance.

9. Citation: Minnesota Rules, part 2960.0080, subpart 18, item A.

Violation: The license holder failed to provide a written response within five days of the resident filing a grievance on the following dates:

a. January 15, 2021 (two grievances); and

b. April 5, 2021 (two grievances).

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

Personnel Files

10. Citation: Minnesota Rules, part 2960.0150, subpart 2.

Violation: Two of five personnel files reviewed for requirements governing staff qualifications (personnel files numbered 2 and 9) did not meet requirements. The license holder did not keep a record showing that staff professional licensure is current.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that staff qualifications meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

11. Citation: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), 245A.19, paragraph (b), 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0100, subpart 3, item A, 2960.0150, subpart 4, item C and 2960.0460, subpart 8, items A and C.

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

a. The file did not include documentation to demonstrate that the staff person received training on the following:

1. The psychosocial development of boys and girls (personnel files numbered 2, 4, 5 and 7);

2. Sexual orientation issues (personnel files numbered 2, 4, 5, and 7);

3. Physical, mental, sensory and health related disabilities, bias and discrimination (personnel file numbered 7);

4. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel file numbered 7);

5. General and special needs, including disability needs of residents and families served (personnel file numbered 7); and

6. Operational policies and procedures, including the drug and alcohol policy (personnel file numbered 7).

b. The staff person did not receive HIV minimum standards training within 72 hours of employment (personnel file numbered 7);

c. The staff person did not receive training on the following within 72 hours of first providing direct contact services to a vulnerable adult (personnel file numbered 7):

1. Vulnerable adults maltreatment reporting requirements and definitions;

2. Program abuse prevention plan; and

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

d. The personnel file of an overnight staff person (personnel file numbered 7) did not include documentation to demonstrate competency in the following topic areas:

1. Knowledge of resident rights and staff responsibilities as outlined in Minnesota Rules, parts 2960.0050 and 2960.0150; and

2. Crisis intervention techniques consistent with the program’s protective procedures plan.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff identified above received training on the items in paragraphs (a) and (d).

12. Citation: Minnesota Statutes, sections 245A.19, paragraph (d), 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0150, subpart 4, item B and 2960.0080, subpart 14.

Violation: Five of five personnel files reviewed for requirements governing annual training did not meet requirements in the following ways:

a. The file did not contain documentation to demonstrate the staff person received annual training in vulnerable adult maltreatment reporting requirements and definitions, the program abuse prevention plan and internal and external policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services in January 2022 (personnel file numbered 9);

b. The file did not include documentation to demonstrate that the staff person received annual training on HIV minimum standards due March 2022 (personnel files numbered 7 through 9);

c. Staff who have direct contact with residents did not complete at least 24 hours of in-service training per year (personnel files numbered 1); and

d. The emergency plan did not meet requirements in the following ways:

1. The plan was not reviewed at least once every six months. The plan review due July 2021 (personnel file numbered 3) and January 2022 (personnel file numbered 9) was not completed; and

2. The plan review due in July 2021 was completed late on October 14, 2021 (personnel files numbered 7 and 8).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure annual training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff identified above received training on the items in paragraphs (a), (b) and (d).

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

13. Citation: Minnesota Rules, part 2960.0100, subpart 5.

Violation: Five of nine personnel fives reviewed for requirements governing the documentation of training did not meet requirements. Training documentation did not include:

a. The number of hours of orientation completed in each topic area (personnel files numbered 2, 4 and 5); and

b. The name of the entity that provided the training (personnel files numbered 2, 4, 5, 7 and 8).

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

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

Violation: The license holder failed to monitor the implementation of the Individual Staff Development and Evaluation Plan which stated “Staff development and evaluation plans will be developed within 90 days of employment and done annually thereafter”. The personnel files did not contain an annual staff development and evaluation plan for the following:

a. Calendar year 2019 (personnel files numbered 8 and 9); and

b. Calendar year 2020 and 2021 (personnel files numbered 6, 8 and 9).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must monitor the implementation of the individual staff development and evaluation plan policy.

15. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D.

Violation: One of four personnel files reviewed for requirements governing medication assistance training (personnel file numbered 7) did not meet requirements. The medication assistance training completed January 6, 2021 was not taught by a registered nurse.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure medication assistance training is taught by a registered nurse. Within 30 days receipt of this order, the license holder must submit verification that the staff person identified above received medication assistance training provided by the registered nurse.

16. Citation: Minnesota Statutes, section 245A.191.

Violation: One personnel file reviewed for requirements governing co-occurring annual training required in Minnesota Statutes, section 254B.05, subdivision 5, paragraph (c) (personnel file numbered 3) did not meet requirements. The staff person did not receive at least eight hours of training on co-occurring disorders in Calendar year 2021.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that co-occurring annual training requirements meet all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

Resident Files

17. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: One of two resident files reviewed for requirements governing the individual abuse prevention plan (resident file numbered 6) did not meet requirements. The IAPP was not developed within 24 hours of the resident turning 18 years old.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual abuse prevention plan meets all applicable requirements.

18. Citation: Minnesota Rules, part 2960.0080, subpart 6.

Violation: One of three resident files reviewed for requirements governing program services (resident file numbered 7) did not meet requirements. The file did not include documentation to demonstrate that the referring or placing agency was immediately notified by the license holder when the resident ran from the facility on December 18, 2021.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must notify the referring or placing agency when a resident runs from the facility and meet all applicable requirements.

19. Citation: Minnesota rules, part 2960.0490, subpart 3, item C.

Violation: Two of two resident files reviewed for requirements governing the individual treatment plan (resident files numbered 6 and 8) did not meet requirements. The treatment plans did not include the frequency of the intervention for each goal.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

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

Violation: Two of two resident files reviewed for requirements governing no eject discharge (resident file numbered 1 and 7) did not include documentation that the license holder conferred with other interested persons to review the issues involved in the decision and develop additional strategies to resolve the issues leading to the discharge and permit the resident an opportunity to continue to receive services.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

21. Citation: Minnesota Rules, part 2960.0190, subpart 2, item B.

Violation: One of two resident files reviewed for discharge documentation (resident file numbered 3) did not meet requirements. The license holder did not document the extent to which the resident’s stay in the facility met the goals and objectives of the resident’s treatment plan including identifying the services, including education that were recommended in the resident’s treatment plan but were not provided to the resident.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 24, 2020.

B. Recommendations

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

1. Initial Services Plan: During the licensing review, DHS licensors observed that the license holder’s initial services plans were not individualized to the needs of the resident. DHS licensing recommends that the license holder develop plans based on the individual needs of the resident upon admission.

Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license.

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

Submissions required as part of a corrective action ordered must be sent to your Licensor at:

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

2. By mail to:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

C. Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

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

Heather Prior, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

651-431-2694

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


facility_name: Winnie Sisu

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.”

Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”

Report Number: 202406718

Date Issued: October 30, 2024

Name and Address of Facility Investigated:

Winnie Sisu
705 18th St NW
Bemidji, MN 56601

Disposition: Maltreatment not determined and Inconclusive.

License Number and Program Type:

1084386-CRF (Children’s Residential Facility)

Investigator(s):

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

651-431-6616

Suspected Maltreatment Reported:

It was reported that a staff person (SP) smoked marijuana with three alleged victims (AV1, AV2, AV3), and a vulnerable adult (VA) on and off facility grounds and did not intervene when the AVs/VA smoked it at the facility.

Date of Incident(s): Prior to August 2, 2024

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

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

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

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a):

The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on August 21, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (the P and the SP), and with AV1, AV2, and AV3. The VA no longer resided at the facility when the site visit was made and was not interviewed for this report. However, the VA provided information in the facility’s Internal Review, and it was included below.

The facility was a transitional residential program that specialized in working with youth who were at risk and worked to build the youths’ independent living skills to prepare them for young adulthood. Youths received services tailored to their needs including daily independent living skills focused groups, one-on-one skills coaching, recreation and leisure opportunities, household management practice, vocational opportunities, and community outings. Community services available to the youths included mental health counseling, psychiatric medication management, chemical dependency services, advocacy, spiritual and cultural resources, and medical and dental care. Off-site education services were provided to the youths by a school district.

Facility documentation showed that AV1 was diagnosed with anxiety and thought that s/he had post-traumatic stress disorder. AV1 was kind and smart but might have difficulty trusting others. No written plans showed whether AV1 had a history of providing inaccurate information, but s/he previously used vaping devices at the facility.

AV2 preferred to spend time in his/her bedroom at the facility and enjoyed one-on-one time with staff persons. AV2 was vulnerable to maltreatment, had difficulty sleeping, was impulsive, and might have verbal aggression toward others, but had no documented history of substance use or providing inaccurate information. AV2 wanted to live as independently as possible.

AV3 was diagnosed with anxiety, was impulsive, was vulnerable to maltreatment, and had a history of substance use. AV3 was outgoing and motivated to build relationships with others, but s/he might struggle with peer interactions, and worked to develop effective communication/conflict resolution skills. AV3 had no documented history of providing inaccurate information.

The VA was diagnosed with anxiety, but s/he was resilient and adaptable, and enjoyed making plans for his/her future. No written documentation showed whether the VA had a history of substance use or a history of providing inaccurate information.

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

· The AVs/VA provided generally consistent information that on July 27, 2024, they went on a community outing with the SP in the facility van. After the outing, the SP stopped at a restaurant to get something to eat, and when the AVs, the VA, and SP walked to and from the van and the restaurant, they saw a marijuana cigarette (a blunt) in the restaurant parking lot. The SP told the AVs/VA to pick up the blunt and bring it with them back to the facility. At the facility, the SP smoked the blunt with the AVs/VA, and AV2 stated that s/he saw the SP “hit the blunt” twice.

· The P, a supervisory staff person, said that in early August of 2024, s/he became aware of talk and discussion among the AVs/VA that they used marijuana with the SP on July 27 and 28, 2024. There were some inconsistencies in the information the AVs/VA provided to the P, but the core of their stories was that the SP took them on a community outing in the facility van on July 27, 2024, and they stopped at a community park and a restaurant. At the restaurant, the SP, the AVs, and the VA saw a blunt on the sidewalk at the restaurant, and did not pick it up initially, but instead began driving back to the facility. However, before reaching the facility, the SP drove back to the restaurant and instructed AV1 to pick up the blunt. AV1 did, and when the AVs, the VA, and the SP returned to the facility, they smoked the blunt in a vacant facility bedroom. The SP gave AV1 the blunt to keep overnight so the SP would not get in trouble and told the AVs/VA not to say anything about using marijuana because the SP might lose his/her job. The next day, the SP took the AVs and the VA on a community outing to a park and smoked the blunt with them again.

· On August 1, 2024, the P asked the AVs and the VA to complete urinalysis (UA) tests and they agreed. AV1’s and AV2’s UAs were positive for tetrahydrocannabinol (THC) which was the substance in marijuana that caused one to feel high. AV3’s and the VA’s UAs were negative for THC and AV3 said that s/he drank water to “flush” marijuana out of his/her system. According to the P, the AVs and the VA had histories of providing inaccurate information, but “not to that magnitude.” Prior to these incidents, there were no concerns regarding the SP’s work at the facility.

· The SP said that when the P called him/her with concerns regarding marijuana use at the facility, the SP was “distraught,” but the P did not give the SP a chance to respond to the concerns. According to the SP, the P said that five youths, including the AVs and the VA, tested positive for marijuana. The SP was very upset and did not recall much of what the P told him/her after that, but on the date of the incident, the SP took the AVs and the VA to get something to eat because there was very little food at the facility and s/he had worked 40 hours in three days and was so hungry and tired that s/he was “about to pass out.” There was enough food for the youths to eat for supper that evening but not enough for the youths to have a second helping if they were still hungry.

· According to the SP, the P told him/her that there were rumors that an unspecified youth picked up a marijuana cigarette at the restaurant parking lot and the SP, the AVs, and the VA returned to the facility, then smoked the marijuana cigarette. The SP told the P that s/he did not know anything about smoking marijuana and denied that s/he smoked it with the AVs/VA. The SP said s/he did not see marijuana at the restaurant or tell a youth to pick it up, denied that used marijuana with the AVs/VA on the community outing to the park, and denied that s/he smoked marijuana at the facility, or smoked it anywhere with the AVs/VA.

· The SP thought that the AVs/VA made up the concerns in this report and relayed them to the P because they called the SP a “bitch,’ said, “Oh fuck, [the SP] is coming” when the SP was scheduled to work, were angry with the SP because the SP told them to go to bed/sleep at 11 p.m., and because s/he followed the facility’s rules when providing care to them. The AVs/VA made comments to the SP and other staff persons that they were going to get the SP “fired.”

· The SP thought that the AVs/VA attempted to obtain marijuana when they were in the community and felt that s/he was being treated unfairly by the facility. In the community, it was difficult to keep constant eyes on the AVs/VA because they interacted with other youths in the parks or might use community bathrooms without direct eyes on supervision. The AVs/VA moved around quickly and were usually in motion. In addition, the AVs/VA went on unsupervised visits with family members during which time they might use marijuana. The SP was unsure whether the AVs/VA had recently visited family members, but they regularly had vaping devices and hid them at school and in the facility van because their belongings were checked when they returned from school, and staff persons took any vaping devices the youths brought to the facility. One of the youths in this report whose identity the SP could not recall, worked in the community, and was not supervised by staff persons at his/her job. The SP thought that the facility’s administrative and supervisory staff persons wanted to get rid of him/her because s/he raised concerns when s/he had them regarding the facility and the way things were done there.

A single instance of marijuana use might cause THC to remain in the urine of a person who had used marijuana for about three days, for approximately four instances of use in one week, THC might remain in the urine for about five days, and if used daily, THC would probably be found in urine for about ten days. If a person used marijuana heavily/chronically, THC might be in urine for 30 days after its last use.

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

Conclusion:

The AVs/VA provided generally consistent information that on July 27, 2024, the AVs, the VA, and the SP found a blunt at a restaurant in the community, and then smoked the blunt together at the facility later that day and smoked more of it in a park on July 28, 2024. The SP asked the AVs/VA not to tell anyone about the marijuana because s/he did not want to get in trouble or lose his/her job. According to the P, on August 1, 2024, the AVs/VA completed UAs which showed that AV1 and AV2 were positive for marijuana, but AV3 and the VA were negative.

The SP said that s/he was upset when s/he learned of the AVs’/VA’s statements and felt that the P did not give him/her a chance to respond. The SP said that s/he did know anything about smoking marijuana, denied that s/he saw marijuana at the restaurant, denied that s/he told a youth to pick it up, and denied that s/he smoked marijuana with the AVs/VA at any time. The SP thought that the AVs/VA might make up things about him/her because s/he followed the facility’s policies and procedures, were upset when the SP was scheduled to work at the facility, planned to get the SP fired, and referred to the SP as a “bitch.”

The P said that the AVs/VA had a history of providing inaccurate information, but not to this extent and prior to this incident, there were no concerns with the SP’s work at the facility.

After a single instance of marijuana use, THC might remain in urine for about three days, after approximately four uses in a week, THC might remain in urine for about five days, and if used daily, THC would probably be in urine for about ten days. After heavy/chronic use, THC might be in urine for 30 days after its last use.

Regarding the AVs:

The AVs/VA said they used marijuana with the SP at the facility and in the community and AV1 and AV2 tested positive for marijuana on the fourth day after their last marijuana use. However, the AVs/VA had a history of providing inaccurate information, AV3 and the VA each tested negative for marijuana, and the SP denied that s/he used marijuana with the youths. Given this, and that there were no other witnesses to the incidents, there was not a preponderance of the evidence that there was a failure to provide the AVs with care or a failure to protect the AVs.

It was not determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Regarding the VA:

The AVs/VA said they used marijuana with the SP at the facility and in the community and AV1 and AV2 tested positive for marijuana on the fourth day after their last marijuana use. However, the AVs/VA had a history of providing inaccurate information, AV3 and the VA each tested negative for marijuana, and the SP denied that s/he used marijuana with the youths. Given this, and that there were no other witnesses to the incidents, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services.

It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years.

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but were not followed. There were no similar past incidents. The facility thought that the SP “allegedly allowed marijuana to be brought into the agency vehicle and the program/house,” and allegedly smoked marijuana with youths and asked a youth to keep a marijuana blunt in his/her possession. The SP was trained on the facility’s Professional Boundaries policy on January 29, 2023, and January 31, 2024. At the time this report was written, the SP was no longer employed at the facility. The facility reviewed professional boundary expectations with all staff persons.

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

No further action taken.

Certification:

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

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

doc_type: Maltreatment Finding


raw_content:
July 22, 2024

Heidi Seaton, Authorized Agent

North Homes Incorporated

4225 Technology Dr. NW

Bemidji, MN 56601

License Number: 1084386 (CRF)

Report Number: 202304881

CORRECTION ORDER

Dear Heidi Seaton:

A Department of Human Services (DHS) licensor conducted a licensing investigation at your facility, Winnie Sisu located at 705 18th St NW, Bemidji, MN 56601. This investigation 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, and under transitional services, Minnesota Rules, 2960.0500, (Rule CRF). 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.

Personnel

1. Violation: The license holder failed to affiliate a staff person (SP1) on each active background study roster for the two licensed programs of the license holder that the staff person was working in. A background study was submitted for a staff person under license number 1087256, however, the staff person identified was also working under license number 1084386.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the affiliation for background study rosters meets all applicable requirements. Within 30 days receipt of this order, the license holder must submit documentation demonstrating all active staff persons that work across the two licensed programs are affiliated to each roster.

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order 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 651-431-6610 or at tina.christensen@state.mn.us .

Sincerely,

Tina Christensen, 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/


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

doc_type: Document