raw_content:
June 24, 2022

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 N., Suite 500

Plymouth, MN 55441

License Number: 1108377

CORRECTION ORDER

Dear Michelle Murray:

On April 26 through 29, 2022, a licensing review of Southeast Regional Crisis Center Nexus located at 2121 Campus Dr. SE., Rochester, MN 55904, 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 residential shelter services under Minnesota Rules, parts 2960.0510 through 2960.0530 (CRF). As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

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

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

Policies and Practices

1. Citation: Minnesota Rules, part 2960.0080, subpart 4, items B and D.

Violation: The facility rules and due process system for residents did not meet requirements for the following topics:

a. The consequences that will be applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior; and

b. The due process system that governs the facility's use of disciplinary consequences.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the facility rules and due process system meets all applicable requirements. Within 30 days of receipt of this order, submit a revised policy that meets all applicable requirements.

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

Violation: The license holder failed to monitor the implementation of practices and policies. The license holders practice was not consistent with the following policies as described below:

a. The license holder reported that the Nursing Supervisor is responsible for providing consultation and review of the administration of medications in which they review at least every patient’s record at least once a month. The license holder’s NURS-708 policy indicates that the Nursing Supervisor will review the Electronic Medication Administration Record (EMAR) weekly for review and consultation; therefore, the license holder failed to implement the weekly reviews according to their policy.

b. The license holder reported that it is their practice and policy to obtain a written signature from a parent or guardian on designated forms to document permission to administer medications to the resident. The NURS-706 policy and work flow chart indicates that the permission is captured on the Client Medication List Upon Admission and the Medical Consent forms. The Medical Consent form was incomplete.

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

Within 30 days of receipt of this order, review and submit policy NURS-708 and NURS-706 that describes the current practice for the program.

Personnel Files

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

Violation: Ten of ten personnel files reviewed for requirements governing orientation training (personnel files numbered 1 through 10) did not meet requirements. Staff were not oriented to the license holder’s program abuse prevention plan within 72 hours of first providing direct contact services.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that staff persons identified above were trained on the program abuse prevention plan to demonstrate compliance.

Resident Files

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

Violation: One of three resident files reviewed for requirements governing resident information (resident file numbered 3) did not meet requirements. The resident’s file did not contain the placing agency’s case plan goals nor did the license holder document and place in the file the attempts made to obtain the placing agency’s case plan goals for the resident.

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

5. Citation: Minnesota Rules, parts 2960.0050, subpart 3, item A, 2960.0080, subpart 4, 2960.0520, subparts 2, items A and B, and 3, item B and C.

Violation: Three of three resident files reviewed for requirements governing admission procedures and plans for immediate needs did not meet requirements in the following ways:

a. The facility rules and due process for residents was not explained verbally and provided in writing to the resident (resident files numbered 1 through 3);

b. There was no documentation to demonstrate that within 24 hours of admission, a written copy of the resident’s basic rights was explained verbally and provided to the resident (resident files numbered 1 and 3); and

c. There was no documentation to demonstrate that when a need for examination was determined from the basic health screening, the license holder notified the resident’s case manager of the need to make an appointment with a medically licensed person to complete the required examination (resident file numbered 2);

d. The license holder did not develop a plan to reduce the resident’s risk of maltreatment while in the program in accordance to their assessment of vulnerability to maltreatment (resident files numbered 1 and 3);

e. The short-term objectives and methods for meeting the identified needs were not specified in the plan for immediate needs (resident files numbered 1 through 3); and

f. The license holder did not indicate their responsibilities for meeting the resident’s needs identified in the plan for immediate needs (resident files numbered 1 through 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure admission procedures and plans for immediate needs meet all applicable requirements. Within 30 days receipt of this order, submit a plan to reduce the resident’s risk for maltreatment and a plan for immediate needs for one resident to demonstrate compliance.

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

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

a. The file did not contain a personal property inventory form upon admission that was signed by the resident (resident files numbered 1 and 3); and

b. The file did not include a signed receipt demonstrating the license holder returned all of the residents’ personal property (resident files numbered 1 through 3).

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

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

Violation: One resident file was reviewed for requirements governing maltreatment of vulnerable adults (resident file numbered 2) and did not meet requirements in the following ways:

a. Documentation to demonstrate the resident was oriented within 24 hours of admission to the program, or 72 hours for persons who would benefit more from a later orientation, to the internal and external reporting procedures governing maltreatment of vulnerable adults, including the telephone number for MAARC and the program abuse prevention plan; and

b. The Individual Abuse Prevention Plan (IAPP) did not contain the following:

1) An individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults;

2) Specific measures to be taken to minimize the risk of abuse to that person when the individual assessment indicates the need for measures.

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

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

Violation: Three of three resident files reviewed for requirements governing safe storage and delivery of medications (resident files numbered 1 through 3) did not meet requirements in the following ways:

a. There was no documentation to demonstrate the license holder contacted the resident’s prescribing medically licensed person to verify the following information regarding their prescription medication:

1) The symptoms that he medication will alleviate; and

2) The symptoms that would warrant consultation with the physician.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. Within 30 days receipt of this order, submit medication verification documentation for two residents to demonstrate compliance.

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

Violation: One resident file was reviewed for requirements governing a no-eject discharge (resident file numbered 3) and did not meet requirements. The file did not contain documentation of the following:

a. The license holder conferred with other interested persons to review the issues involved in the decision to discharge a resident prior to reaching their case plan goals;

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

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

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

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. During the licensing review it was unclear if program staff were utilizing time out procedures. DHS Licensing recommends the license holder incorporate the definition of time out in its emergency procedure and explicitly indicate if it is permissible or not. If the license holder chooses to utilize time out the license holder must follow the required requirements under MN Rule 2960.0080, subpart 5, item D.

2. DHS licensing recommends the license holder to coordinate with similar/alike licenses across the organization to ensure a better understanding and compliance on all applicable rules and statutes with Minnesota Rules, chapter 2960.

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

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

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

2. By mail to:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

C. Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

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

Tina Christensen, Human Services Senior Licensor

Licensing Division

Office of Inspector General

651-431-6610

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


state: MN

facility_name: Southeast Regional Crisis Center Nexus

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


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


facility_name: The Freedom Ranch

report_date: February 25, 2026

raw_content:
February 25, 2026                   CERTIFIED MAIL

Andrea Drake, Authorized Agent

Rising Hope Foundation

16966 County Road 2

Brainerd, MN 56401

License Number 1116745 (CRF)

ORDER TO PAY A FINE

Dear Andrea:

The Department of Human Services (DHS) is ordering you to pay a fine of $100 for one licensing violation at your Children’s Residential Facility (CRF) located at 16966 County Road 2 in Brainerd, MN 56401. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

1.  Other Licensing Violation

The Department of Human Services (DHS) and your program, The Freedom Ranch, located at 16966 County Road 2 Brainerd, MN, 56401, entered into a settlement agreement on April 25, 2025. Term number 4, paragraph (c) of the settlement agreement requires the license holder to submit findings related to their self-monitoring of compliance to their licensor on the 15th of the month following the quarter.

As of January 15, 2026, DHS had not received documentation of the required self-monitoring of compliance regarding 2025 Quarter 4.

Fine: $100

Corrective Action Required: Maintain compliance with all terms of the settlement agreement. Under term number 6 of the settlement agreement dated April 25, 2025, the license holder’s failure to comply with the terms of the agreement may result in immediate reinstatement of the Conditional Order.

Statute Violated: Minnesota Statutes, section 245A.06, subdivision 1.

Billing and Payment of the Fine

DHS will send you an invoice for the $100 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, you are personally responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

YOUR RIGHT TO APPEAL

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: 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 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $100 fine for each occurrence of a licensing violation that is not related to health, safety, supervision, or maltreatment under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(v).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

Questions

If you have any further questions regarding this matter, you may contact Paula Halverson, Manager, at 651-431-5653.

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/

doc_type: Notice of Violation


report_date: October 3, 2025

raw_content:
October 3, 2025

Andrea Drake, Authorized Agent

Rising Hope Foundation

16966 County Road 2

Brainerd, MN 56401

License Number: 1116745

CORRECTION ORDER

Dear Andrea Drake:

On April 25, 2025, the Department of Human Services (DHS) and your program, The Freedom Ranch, located at 16966 County Road 2 Brainerd, MN, 56401, entered into a settlement agreement. A correction order is being issued due to The Freedom Ranch not following terms of a settlement agreement as required under Minnesota Statutes, chapter 245A.

REASON FOR CORRECTION ORDER

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

The following violations of state or federal laws and rules were determined as a result of not complying with terms of the settlement agreement. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

VIOLATIONS

1. Violation: The license holder did not comply with term G of the settlement agreement, effective on April 25, 2025:

a. The license holder did not report to DHS a change in the role of Compliance Officer.

Statute Violated: Minnesota Statutes, section 245A.081.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all the terms of the settlement agreement are followed. Within 14 days receipt of this order, the license holder must submit to DHS Licensing a resume for any proposed Compliance Officer the identifies two years of professional experience in a regulatory or compliance position or in providing direct care services to youth in a children’s residential facility, and the ability to understand and interpret rules and statutes. The program’s Compliance Office may only allocate 50 percent of their working hours to direct care services. The program’s Compliance Officer must be approved by the program’s DHS Licensor.

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 hannah.horsch@state.mn.us or by 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:

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 651-431-6270 or at hannah.horsch@state.mn.us.

Sincerely,

Hannah Horsch, Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


raw_content:
August 20, 2025

Andrea Drake, Authorized Agent

Rising Hope Foundation

16966 County Road 2

Brainerd, MN 56401

License Number: 1116745

CORRECTION ORDER

Dear Andrea Drake:

On April 25, 2025, the Department of Human Services (DHS) and your program, The Freedom Ranch, located at 16966 County Road 2 Brainerd, MN, 56401, entered into a settlement agreement. A correction order is being issued due to The Freedom Ranch not following terms of a settlement agreement as required under Minnesota Statutes, chapter 245A.

REASON FOR CORRECTION ORDER

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

The following violations of state or federal laws and rules were determined as a result of not complying with terms of the settlement agreement. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Violations

1. Violation: The license holder did not comply with terms C and E of the settlement agreement, effective on April 25, 2025:

a. The license holder did not implement the DHS self-monitoring plan and submit a quarterly report by July 15, 2025, that included:

i. A summary of any patterns of problems identified in monthly reviews of policies and procedures, practices, and client files;

ii. A description of the strategies put in place to address any non-compliance determined;

iii. Corrective actions taken; and

iv. A determination of whether the corrective action taken was effective.

b. The license holder did not submit to DHS a personnel training plan that outlines the contents of each topic that staff are trained on, who provides the training, how the training is delivered, and how staff competency is evaluated. The training plan submitted does not include all training requirements required by Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0100, subparts 3 and 5, and 2960.0150, subpart 4.

Statute Violated: Minnesota Statutes, section 245A.06, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that all the terms of the settlement agreement are followed. Within 10 days of receipt of this order, submit a quarterly report and personnel training plan that meets all requirements of the settlement agreement and applicable statute and rule requirements. You must include a copy of the checklists used.

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 hannah.horsch@state.mn.us or by 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:

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 651-431-6270 or at hannah.horsch@state.mn.us.

Sincerely,

Hannah Horsch, Licensor

Licensing Division

Office of Inspector General

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


report_date: December 31, 2024

raw_content:
PUBLIC

Summary of Settlement Agreement

License Holder: The Freedom Ranch

License Numbers: 1116745

Program Type: Children’s Residential Facility

Date of Licensing Action: December 31, 2024

Licensing Action Taken: Order of Conditional License

Reconsideration requested and settlement agreement signed by Commissioner on: April 25, 2025

Terms of Settlement Agreement: License Holder agreed to withdraw the request for reconsideration and DHS agreed not to impose the Order. License Holder agreed to comply with specified terms for two years from the effective date of the Settlement Agreement.

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

doc_type: Order


raw_content:
December 31, 2024

CERTIFIED MAIL

Jenny Cushing, Authorized Agent

The Freedom Ranch

16966 County Road 2

Brainerd, MN 56401

License Number: 1116745 (CRF)

ORDER OF CONDITIONAL LICENSE

Dear Jenny Cushing:

The Department of Human Services (DHS) is placing your license to provide at The Freedom Ranch, 16966 County Road 2 Brainerd, MN, on conditional status for two years, beginning December 31, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Children’s Residential Facilities licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed.

REASON FOR THE CONDITIONAL LICENSE

On November 4 and 5, 2024, DHS licensors conducted a licensing review and investigation at your facility located at 16966 County Road 2 in Brainerd, MN. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Children’s Residential Facilities, citing 17 violations. DHS has considered the nature and severity of these violations, as well as the health, safety, and rights of children by the program.

· Nature / severity:

o The license holder failed to maintain awake staffing and supervision on October 6, 8 and 9, 2024, and was cited in a fine order issued on October 23, 2024;

o The license holder failed to comply with background study requirements prior to staff working in a children’s residential facility (violation number 1);

o The license holder failed to comply with the terms of a background study variance (violation number 2);

o The license holder failed to retain and store program administration and client records (violation number 3);

o The license holder failed to train staff on medication administration prior to them administering medications (violation number 4);

o The license holder failed to comply with the applicable health codes and did not have a Certified Food Manager on staff (violation number 5); and

o The license holder failed to comply with requirements of staff orientation training (violation number 6).

Due to the serious 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 group residential services in a Children’s Residential Facility 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: The license holder failed to meet background study requirements for two staff members required to have a background study before the individual began working in the facility (personnel files numbered 4 and 5).

As the result of a licensing review on November 4 and 5, 2024, a DHS licensor determined that the license holder did not initiate a background study on two staff persons (personnel files numbered 4 and 5) before s/he began working in the facility. Working in a children’s residential facility without having received a required notice is prohibited.

Staff (personnel files numbered 4 and 5) were hired as a Registered Nurse (RN) to provide oversight of the program’s health care and medication administration policies and procedures. The license holder did not maintain personnel files or any related background study documentation that could demonstrate when they began working in the facility. Program staff confirmed that staff (personnel files numbered 4 and 5) had been on site at the facility and had met with residents. At the time of the licensing review on November 4 and 5, 2024, the license holder had not submitted a background study request to DHS for staff (personnel files numbered 4 and 5) and as a result, had not received the notice required to allow them to work in the facility.

Rule Violated: Minnesota Statutes, section 245C.03, subdivision 1.

2. Violation: The license holder failed to comply with the terms of a background study variance issued to a staff person (personnel file numbered 6). The license holder did not ensure that the staff person always worked with another employee with a cleared background study and did not have documentation to demonstrate that the staff person received supervision for the months of April, August, or September 2024.

Rule Violated: Minnesota Statutes, section 245C.30, subdivision 1.

3. Violation: The license holder failed to retain and store records in a manner that allowed for review by the commissioner during the licensing review and licensing investigations; therefore, the following records were not maintained in accordance with applicable state or federal law, regulation, or rule for the following:

a. Program administration records of satisfaction surveys according to Minnesota Rules, part 2960.0140, subpart 1, item B; and

b. Client file paperwork, including verification of service delivery according to Minnesota Rules, part 2960.0180, subpart 3, item C (resident file numbered 1 and 2).

During the licensing review, a staff member informed licensors that the documents had either been thrown out or were otherwise misplaced.

Statute Violated: Minnesota Statutes, section 245A.041, subdivision 3.

4. Violation: Eleven of fifteen personnel files reviewed for requirements of rules governing medication assistance training did not meet requirements. Medication administration records demonstrated that the staff persons administered medications to residents without having received training by a registered nurse during the months of January through October 2024 (personnel files numbered 3, and 6 through 15).

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

5. Violation: The license holder failed to comply with the applicable health codes. The license holder did not have a Certified Food Manager on staff from October 14, 2024, to November 5, 2024.

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

6. Violation: Six of six personnel files reviewed for orientation training did not meet requirements:

a. There was no documentation that staff successfully completed orientation training before having unsupervised contact with residents on the following topics (personnel files numbered 1, 4, and 5):

i. Emergency procedures;

ii. Maltreatment of minor reporting requirements under Minnesota Statutes, section 260E;

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

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

v. Operational policies and procedures; and

vi. Data practice regulations and issues.

b. There was no documentation that staff were oriented to the following required topics:

i. Gender issues, including the psychosocial development of boys and girls (personnel files numbered 1, 4, and 5);

ii. Sexual orientation issues (personnel files numbered 1, 4, and 5);

iii. Drug and alcohol policy (personnel files numbered 1, 2, 4, and 5); and

iv. Staff’s duties in implementing the program’s policies and procedures (personnel files numbered 1 through 6).

c. The license holder did not have documentation of the date and number of hours of orientation completed in each topic area and the name of the entity who provided the training (personnel files numbered 1 through 6).

Statute and Rule Violated: Minnesota Statutes, section 245A.04, subdivisions 1, paragraph (c) and 14, paragraph (b), and Minnesota Rules, parts 2960.0100, subparts 3, item A, and 5, and 2960.0150, subpart 4, item C.

7. Violation: Two of two resident files reviewed for rules governing no-eject procedures did not meet requirements (resident files numbered 1 and 2). For residents who were discharged prior to reaching their case plan goals, requirements were not met 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;

b. There was no documentation to demonstrate the license holder determined whether the license holder, treatment team, interested persons, and the resident could develop any additional strategies to resolve the issues leading to discharge and to permit the resident an opportunity to continue to receive services from the license holder; and

c. Documentation did not identify alternatives to discharge that were considered or attempted.

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

8. Violation: Three of three resident files reviewed for rules governing admission procedures did not meet requirements in the following ways:

a. The inventory of the resident’s personal property did not include the resident’s signature, or two staff signatures if the resident refused to sign (resident files numbered 1);

b. There was not documentation that the license holder communicated to the resident the facility’s rules and due process system (resident files numbered 1 and 2);

c. There was no documentation that a written copy of the resident’s basic rights was given to the resident and explained to them if the resident was incapable of understanding the written document within 24 hours of admission (resident files numbered 1 and 2);

d. There was not documentation that the residents’ guardians were informed that information on the resident’s basic rights is available (resident files numbered 1 through 3);

e. There was not documentation that copies of the facility rules were not made available to all residents at the time of admission (resident files numbered 1 and 2); and

f. There was not documentation that residents were provided with a copy of a description of the applicable programs and activities available to residents in the facility within 24 hours of admission (resident files numbered 1 through 3).

Rule Violated: Minnesota Rules, parts 2960.0050, subpart 3, items A and B, 2960.0070, subpart 4, 2960.0080, subpart 4, and 2960.0160, subpart 4, items A and B.

9. Violation: The license holder failed to monitor the implementation of their policies and procedures. The license holder had two different versions of information on resident rights.

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

10. Violation: The license holder did not have a copy of the rights posted in the staff work station.

Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item D.

11. Violation: The license holder’s grievance procedure did not include the following:

a. The allowance of a resident’s parent or legal representative, a guardian, or a concerned person in the resident’s life to make a formal complaint or suggestion or express a concern about any aspect of the resident’s care during the resident’s stay in the facility;

b. Who the authorized person to resolve the complaint is and the ability to carry the grievance forward to the highest level of administration;

c. That a person who reports a grievance will not be subject to adverse action by the license holder as a result or filing the grievance; and

d. That the person filing a grievance will receive a response within five days.

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

12. Violation: Three of three resident files reviewed for rules governing admission criteria did not meet requirements. Documentation did not include the following required components:

a. Whether the program could meet the resident’s needs (resident files numbered 1 through 3),

b. Whether the resident was a danger to themselves or others (resident file numbered 1); and

c. Whether the program was able to meet the resident’s cultural, emotional, educational, mental health, or physical needs (resident files numbered 1 through 3).

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

13. Violation: Three of three resident files reviewed for rules governing admission screenings did not meet requirements in the following ways:

a. The health screening was not completed (resident files numbered 1 through 3);

b. A mental health screening was not completed (resident file numbered 1);

c. A substance use disorder screening was not completed (resident files numbered 1 and 2);

d. An education screening was not completed (resident files numbered 1 through 3);

e. A gender-specific screening was not completed (resident files numbered 1 through 3); and

f. Inquiries and the results of the inquiries regarding the degree to which the resident and the resident’s family desires for the resident’s family to be involved during the resident’s stay at the facility were not documented (resident files numbered 1 through 3).

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

14. Violation: Three of three resident files reviewed for rules governing treatment plans did not meet requirements in the following ways:

a. There was no documentation to demonstrate that they began to develop a treatment plan within ten days of admission (resident file numbered 1);

b. There was no documentation to demonstrate the resident was assigned to a designated staff person to monitor and assist the resident in implementing the treatment plan (resident files numbered 1 through 3).

Rule Violated: Minnesota Rules, parts 2960.0180, subpart 2, item B

15. Violation: Three of three resident files reviewed for rules governing health care did not meet requirements. The license holder did not have documentation of the following:

a. That the license holder contacted the resident’s prescribing medically licensed person to verify the symptoms that the medication will alleviate (resident files numbered 1 and 2) and the symptoms that would warrant consultation with the physician (resident files numbered 1 through 3);

b. Attempts to contact the resident’s guardian to seek permission to administer the medication (resident files numbered 1 through 3);

c. The prescribing physician’s directions for monitoring medications used by the resident (resident files numbered 1 through 3);

d. The disposition of a resident’s prescription medication upon discharge (resident files numbered 1 and 2).

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

16. Violation: One of two resident files reviewed for rules governing discharge procedures did not meet requirements. The license holder did not have documentation to demonstrate that they returned all of the resident’s personal property to them upon discharge (resident file numbered 2).

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

17. Violation: Three of six personnel files reviewed for rules governing staff qualifications did not meet requirements. The file did not contain documentation to demonstrate staff met the following qualifications:

a. The staff had been trained in gender-based needs and issues (personnel files numbered 1, 4, and 5);

b. The staff member is at least 21 years old (personnel files numbered 4 and 5); and

c. The professional licensure is current (personnel files numbered 4 and 5).

Rule Violated: Minnesota Rules, parts 2960.0100, subpart 6, items B and C, and 2960.0150, subpart 2.

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 Children’s Residential Facilities 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.

Please submit documentation via the following methods:

1. By secure email to: hannah.horsch@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services
ATTN: Hannah Horsch
Licensing Division
PO Box 64242
St. Paul, MN 55164-0242

Additionally, DHS will not approve a request to license another program setting from the date of this order until the time your conditional license expires.

CONDITIONAL LICENSE TERMS

In addition to the Children’s Residential Facility 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 that 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 submit to DHS Licensing a resume for any proposed Compliance Officer that addresses each qualification listed below. The license holder agrees to ensure that the program’s Compliance Officer will not hold the position of Program Director. If providing direct care services, the Compliance Officer may only allocate 50 percent of their working hours to direct care services. The resume must address each qualification listed below. The program’s Compliance Officer must have the following minimum qualifications and must be approved by the program’s DHS Licensor:

a. 2 years of professional experience in the following:

1) A regulatory or compliance position; or

2) Providing direct care services to youth in a children’s residential facility; and

b. Working knowledge of Minnesota Statutes, Chapter 245A, Human Services Licensing and Minnesota Rules, chapter 2960.

3. Within 30 days of the receipt of this order, you must implement the DHS Licensing self-monitoring plan that ensures an ongoing, systematic approach for monitoring compliance with applicable licensing laws, rules, and statutes. The Compliance Officer must conduct, within the first quarter, a review of the license holder’s policies and procedures to ensure compliance with Minnesota Statutes, Chapters 245A and Minnesota Rules, chapter 2960. This includes an assessment of staff implementing the policies and procedures.

Documentation requirements of the results of the monthly reviews are outlined in the DHS self-monitoring plan. Documentation of the discrepancies found when conducting the reviews and the corrective actions taken must be submitted to the program’s DHS Licensor quarterly, and continuing every three months thereafter, on the 15th of month following the quarter, for 2 years from the effective date of the conditional license or otherwise determined by DHS licensing.

4. Within 30 days receipt of this order, the Authorized Agent, Program Director and Compliance Officer (upon hire) must read Minnesota Statutes, chapters 245A and 245C, and Minnesota Rules, parts 2960.0010 through 2960.0220 and contact your licensor to arrange a competency evaluation to demonstrate your knowledge of the applicable Minnesota Statutes and Rules.

5. Within 30 days receipt of this order, you must submit to DHS a personnel training plan that outlines all topics staff are trained on, the contents of each training, who provides the training, how the training is delivered, and how staff competency is evaluated. You must include a mock personnel file that contains orientation and training checklists required of group residential facilities.

6. Within 45 days of receipt of this order, you must submit a fully revised and compliant policy and procedure manual in electronic format to DHS for review and approval. The policy and procedure manual must include all of the necessary policies and procedures the license holder requires to maintain compliance with the licensing requirements under Minnesota Statutes and Minnesota Rules. The policy and procedure manual must explicitly identify the policies and procedures applicable to the licensing requirements that govern the children’s residential facility license.

Within 14 days of the approval from DHS Licensing, the license holder must train all program staff to their duties in implementing the program’s policies and procedures and submit a training record to DHS Licensing demonstrating the completion of the training.

7. Throughout the duration of the conditional license, any changes to program leadership staff must be reported to and approved by DHS Licensing, before the staff person assumes responsibilities of the role. Leadership staff includes the Authorized Agent, Program Director, Sensitive Information Person (background studies), and Compliance Officer.

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

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 10 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

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 Children’s Residential Facilities laws and rules.

Legal authority for this licensing action

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

· Group residential settings are required to follow Minnesota Rules, parts 2960.0130 – 2960.0220.

· 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/


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10/23/2024                    CERTIFIED MAIL

Vicki Leckie, Authorized Agent

Rising Hope Foundation

15959 Blue Heron Drive

Brainerd MN 56401-6098

License Number: 1116745 (CRF)

Report Number: 202408794

ORDER TO PAY A FINE

Dear Vicki Leckie:

The Department of Human Services (DHS) is ordering you to pay a fine of $600 for three licensing violations at your Children’s Residential Facility, The Freedom Ranch, located at 16966 County Road 2, Brainerd MN 56401. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

1. Supervision Violation

As a result of a licensing investigation conducted on October 11, 2024, a DHS licensor determined that the license holder failed to supervise children in care.

On October 6, 8 and 9, 2024, there was not at least one staff person present and awake at all times in the facility when residents are normally asleep. The license holder instead had a staff member in an attached apartment unit asleep during the shifts.

Fine: $200 for each occurrence (October 6, 8 and 9, 2024).

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

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

Billing and Payment of the Fine

DHS will send you an invoice for the $600 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is personally and jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

YOUR RIGHT TO APPEAL

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: 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 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attention: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

Legal representation at the contested case hearing

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $200 fine for each health, safety, or supervision licensing violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

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/


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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: 202406474  Date Issued: August 28, 2025

Name and Address of Facility Investigated:

The Links Youth Emergency Shelter Program dba Dignity House

Disposition: Maltreatment determined as to neglect of two alleged victims by a staff person.

License Number and Program Type:

1104909-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas/Alice Percy

Minnesota Department of Human Services Office of Inspector General

Licensing Division PO Box 64242

Saint Paul, Minnesota 55164-0242 Gessner.Rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that a staff person (SP) called alleged victims (AV1 and AV2) names including calling AV1 “dumb, retarded, and stupid” and using other slurs about AV1’s size and calling AV2 “fat and disgusting.” [Note: Throughout the remainder of the report the word “retarded” will be referred to as the R-word.] The SP also punished AV1 by sending him/her to bed without food and made comments about AV1’s underwear in front of the other children, resulting in AV1 running away from the facility.

Date of Incident(s): Ongoing, prior to July 26, 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 September 11, 2024; from documentation at the facility; and through eight interviews conducted with a facility staff person (P1), an administrative staff person (P2), the SP, AV1, AV2, two of AV1’s guardians (G1 and G2), and AV2’s foster parent (FP).

AV1 was sixteen years old at the time of the incidents. AV1 diagnoses included autism and asthma. AV1 moved to the facility after refusing to return to his/her foster home.

AV2 was fifteen years old at the time of the incidents. AV2’s diagnoses included attention-deficit hyperactivity disorder (ADHD), depression, and post-traumatic stress disorder (PTSD). AV2 was admitted to a hospital after assaulting a family member.

The facility provided emergency shelter services to youth ages 10 to 17 who have run away from home, are experiencing homelessness and/or who are involved in the child welfare and juvenile justice systems.

AV1 provided the following information:

· AV1 lived at the facility on two occasions and living there was “cool for a while” until the SP told AV1 that s/he was a “dumb, [R-word], and stupid individual” on multiple occasions. On some occasions, the SP told AV1 that AV1 “disrespected” the SP, so the SP sent AV1 to bed without food. On one occasion, the SP told AV1 in front of the other residents that s/he had a “wedgie” which caused “shit stains” on AV1’s underwear. The incidents occurred in mid-October 2024. AV1 did not recall the names of the other youth who were present when the SP made the comments. AV1 became upset and ran away from the facility because s/he could not handle the SP calling him/her names. At some point, AV1 told P2 about the comments the SP made about AV1 and the SP did not work at the facility again.

· The SP frequently told the youth that the staff persons only worked at the facility for a paycheck and that they did not care about the youth. At times the SP refused to cook food for the youth so another staff person would have to do the cooking. On other occasions, the residents had to cook breakfast or lunch for themselves because there were no other staff persons besides the SP at the facility. Sometimes, the SP made food for him/herself and then not for the youth.

AV2 provided the following information:

· On numerous occasions, the SP called AV2 fat. On one occasion, AV1 was present when the SP called AV2 fat. The SP was also rude to AV1 and called him/her “[R-word].” The SP was “nice” when AV2 first moved into the facility, but then “got rude” and told AV2 that s/he was not going to be the SP’s “favorite” youth anymore. The SP did not let AV2 do things like watch television and made AV2 sit in his/her bedroom.

· The SP told the youth that s/he did not care about any of them and was only working there to make money. The SP also told the youth not to “talk bad” about the SP or the SP would “get kicked out.”

· The SP “barely cooked” when s/he was at the facility and sent AV1 to bed without making food for AV1. AV2 “didn’t think [the SP] fed any of us either.” The SP frequently brought food for him/herself to the facility, but did not cook for the youth. If other staff persons were not present to cook, the SP told the youth they were “old enough to cook for yourselves.”

P1 provided the following information:

· P1 stated that s/he heard the SP call the youth “fat, dumb, and stupid.” The SP would also “snatch” cell phones from the youth and refuse to give them food. Any time AV1 did anything “wrong,” such as vaping, the SP told AV1 that s/he was “[R-word].” P1 believed that the SP made similar comments to the youth “every weekend” that P1 worked with the SP. The SP also threatened staff persons. AV2 told P1 that the SP told the youth that the SP was “only here for the paycheck and did not care about” the youth.

· P1 stated that on several occasions, the SP brought food to the facility for him/herself, but did not make food for the youth. At those times, P1 cooked food for the youth. While the staff persons were supposed to work as a team, the SP typically “would do nothing.” On one occasion in June 2024, the SP punished AV1 by sending him/her to bed without food so P1 made food for AV1.

· P1 told P2 about the SP’s comments because s/he did not feel comfortable with the way the SP treated the youth and the staff persons. Other staff persons also complained about the SP because s/he “did not treat anyone well.”

P2 provided the following information:

· P2 stated that AV1 lived at the facility twice, from May to October 2023 and March to August 2024.

· P2 stated that another administrative staff person (P3) periodically “checked in” with the youth. AV1 told P3 that the SP made negative comments to AV1 and the other youth. The SP called AV1 “[R-word]” and told AV1 that s/he had “shitty drawers” in front of the other youth. After AV1 left the facility, s/he did not want to return to the facility because of the SP’s comments. P2 and P3 talked to the youth and other staff persons about the SP’s interactions. The facility put the SP on leave while the allegations were investigated. The SP no longer worked at the facility.

· AV2 told P2 that the SP sometimes brought food to the facility for him/herself, but did not make food for the youth. P2 stated that the facility’s policies stated that the staff persons could not withhold food from the residents.

The SP provided the following information:

· The SP stated that s/he never called a youth dumb, the R-word, or stupid and never said those things to AV1. The SP never sent AV1 to bed without food. AV1 “would never eat” and the staff persons “begged” him/her to do so. When AV1 went on community outings with his/her family member, s/he returned to the facility

and told the staff persons s/he was not hungry. AV1 then went to his/her bedroom or outside to play basketball.

· On one occasion, AV2 told AV1 that s/he had a “wedgie” and “shit stains on [his/her] underwear.” The SP asked AV2 not to swear. The SP did not know why AV1 would say that the SP made the comment.

· The SP never told the youth that s/he was only working at the facility for the paycheck and did not care about the youth. The SP and the other staff persons prepared food for the residents. At times, the SP spent his/her own money to buy pizza for the youth. When another staff person prepared food for the youth, the SP completed the paperwork. If s/he was the only staff person at the facility, s/he prepared food for the youth. The SP documented when s/he prepared food for the youth. AV1 “never ate” and told the staff persons that s/he was not hungry even though the staff persons, including the SP, “begged” AV1 to eat.

· The SP never told AV2 that s/he looked “fat and disgusting.” P1 and AV2 had “a joke” in which AV2 was referred to as “big back,” but the SP did not refer to AV2 as “big back.” When the SP asked P1 why s/he engaged with the youth that way, P1 told the SP that s/he was having “harmless fun” with the youth. When the SP complained to his/her supervisors about P1’s interactions with the residents, “nothing was done.” The SP did not provide any additional information about who s/he talked to or when s/he talked to them. The SP believed that AV2 “had a big dislike” of the SP.

· The SP did not tell the youth that s/he only worked at the facility for the paycheck.

G1 stated that s/he was AV1’s previous guardian. At that time, AV1 frequently had complaints about the staff persons, but never told G1 that s/he was sent to bed without food. AV1 “always got extra food” from his/her family member. AV1 “talked down” about him/herself and was very self-deprecating.

G2 stated that AV1 lived at the facility from March to August 2024. During that time, AV1 complained about it because s/he felt that s/he was “dumped there” and wanted to move. G2 believed AV1’s complaints were “baseless reasons” to try and transfer out of the facility. The staff persons at the facility were “supportive and communicative.”

The FP stated that on one occasion while s/he was on the telephone talking to AV2, s/he overheard P1 questioning AV2 about something. The FP did not hear P1 curse or use derogatory words toward AV2.

According to the facility’s Employee Handbook, the staff persons were conduct themselves in a professional manner, to behave and communicate in a businesslike manner, and to be courteous and respectful.

According to the facility’s Policies & Procedures Manual, the residents had a right to be free from abuse, neglect, inhumane treatment, and sexual exploitation. The residents had the right to nutritious and sufficient meals as well as the right to courteous and respectful treatment. The residents also had the right to be free from restraint and seclusion used for any purpose other than to protect the residents from imminent danger to themselves or others. All of the residents were to be provided with three meals per day as well as snacks. The staff persons were prohibited from using corporal punishment, name calling, making derogatory statements about the clients, making statements intended to shame, threaten, humiliate, or frighten the residents, or withholding basic needs such as a nutritious diet.

Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incidents.

Conclusion:

A. Maltreatment:

Although it was reported that the SP sent AV1 to bed without food, consistent information was provided that although the SP sometimes did not cook food for the residents, other staff persons or the residents themselves would then cook food.

AV1 stated that on multiple occasions, the SP called him/her “dumb, [R-word], and stupid” and also told AV1 in front of the other residents that AV1 had a “wedgie,” which caused “shit stains” on AV1’s underwear. AV1 became upset and ran away from the facility because s/he could not handle the SP calling him/her names. AV2 stated that on numerous occasions, the SP called AV2 fat and made other “fat” comments about AV2 and that the SP called AV1 “[R-word].”

Although the SP denied calling AV1 and/or AV2 names, given that P1 stated s/he heard the SP call AV1 “[R-word]” and also call youth “fat, dumb, and stupid,” which was consistent with the information provided by AV1 and AV2, and that the SP had reason to minimize his/her interactions for fear of repercussions, it was more likely that the SP engaged in the actions as described by P1, AV1, and AV2. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were a violation of the facility’s policies. Given that the SP used repeated language toward AV1 and AV2 that might have hindered their ability to have a trusting relationship with the facility’s staff persons and the egregious nature of the R-word, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with necessary care and/or a failure to protect AV1 and AV2 from actions that seriously endangered their mental health when reasonably able to do so.

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

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

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

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

should have known of the errors and took no reasonable measures to correct the defect before administering care;

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

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

Facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incidents.

The SP was responsible for maltreatment of AV1 and AV2.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible was determined to be recurring, the SP was responsible for the neglect of AV1 and AV2. However, the substantiated neglect did not meet the definition of serious maltreatment.

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 the facility’s policies were adequate and were followed by the staff persons. The SP no longer worked at the facility.

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

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

Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above.

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.

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doc_type: Maltreatment Finding