report_date: February 27, 2023

raw_content:
February 27, 2023

Tony Sanders, Authorized Agent

Grafton Integrated Health Network

3150 Shawnee Dr.

Winchester, VA 22601

License Number: 1109203 (PRTF)

Investigation Report Numbers: 202205014

202207890

CORRECTION ORDER

Dear Tony Sanders:

On October 19 through 21, 2022, and October 26 through 28, 2022 a modified licensing review and investigation of Grafton Integrated Health Network Minnesota Psychiatric Residential Treatment, located at 224 Kray Mill Rd., Cold Spring, MN 56320, was conducted to determine compliance with state and federal laws and the variance governing Psychiatric Residential Treatment Facilities (PRTF) under Minnesota Rules, part R2960V. As a result of this licensing review and investigation 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.

Postings, Policies, and Practices

1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a) and Minnesota Variance R2960V.04, subpart 2, item B.

Violation: The license holder’s postings did not meet requirements in the following ways:

a. The program abuse prevention plan (PAPP) was not posted in a prominent location in the program; and

b. A copy of the resident’s rights was not maintained where it could be readily accessed by staff and residents.

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

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

Violation: Two of two internal reviews of alleged maltreatment reviewed did not meet requirements in the following ways:

a. The internal review of an incident dated July 13, 2022, did not include an evaluation of whether policies and procedures were followed; and

b. The internal review of incidents dated June 14, and July 13, 2022, did not include the following required documentation:

1. Documentation to demonstrate the review was completed within 30 days;

2. An evaluation of if there was a need for additional staff training;

3. If the reported event was similar to past events with the children or services involved; and

4. If there was a need for corrective action 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 the completion of internal reviews meets all applicable requirements.

3. Citation: Minnesota Variance, section R2960V.13.

Violation: The license holder failed to ensure that all treatment team members participated in clinical supervision or an ancillary meeting for each calendar week they worked in four of four weeks reviewed, for the weeks of:

a. October 12, 2022;

b. September 14, 2022;

c. August 24, 2022; and

d. July 6, 2022.

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

4. Citation: Minnesota Variance, section R2960V.14, subparts 2 and 4.

Violation: The program’s access to a licensed mental health professional did not meet requirements. Treatment staff were not ensured access, either in person or by telephone, to a licensed mental health professional within 30 minutes. The license holder did not maintain a schedule of the available licensed mental health professionals.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure access to a licensed mental health professional meets all applicable requirements.

5. Citation: Minnesota Variance, section R2960V.15, subpart 8.

Violation: The license holder failed to provide notification to a resident when a student trainee provided treatment services.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the notification of student trainees providing treatment services meets all applicable requirements.

6. Citation: Minnesota Variance, sections R2960V.11, subpart 5, and R2960V.17, subpart 1.

Violation: The license holder did not conduct a review of the quality assurance plan and the data and information related to each of the required components, including resident outcomes, restraint and seclusion data, critical incidents and self-monitoring of compliance.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure to conduct a quarterly review of the quality assurance and improvement plan that meets all applicable requirements.

7. Citation: Minnesota Variance, section R2960V.12, item A.

Violation: Three of twenty-seven incident reports reviewed for requirements governing critical incident reports did not meet requirements in the following ways:

a. The critical incident report was not reported to DHS within 10 days, for incidents dated:

1. July 13, 2022; and

2. September 26, 2022

b. An incident report dated August 21, 2022, met the definition of a critical incident and was not reported to DHS. The incident required a response by law enforcement and ambulance.

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

Personnel Files

8. Citation: Minnesota Statutes, sections 245C.03, subdivision 1, 245C.04, subdivision 1, and 245C.13, subdivision 2.

Violation: As a result of a licensing review, a DHS licensor determined that the license holder failed to request a background studies (BGS) for one staff person before they began working in a position allowing direct contact with residents, or before an adult, regardless of whether or not the individual will have direct contact with persons served by the children’s residential facility, began working in the facility or setting.

a. Staff person (SP9) began a position working in the facility which allowed for direct contact with persons served by the program on September 5, 2022. However, the license holder did not submit a BGS request until September 19, 2022.

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

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

9. Citation: Minnesota Variance, section R2960V.15, subpart 5.

Violation: Nine of nine personnel files reviewed for requirements governing staff files did not meet requirements. The files did not include:

a. Verification of the staff persons qualifications specific to the position including required credentials and/or professional licensure (personnel file numbered 5);

b. The date of hire (personnel files numbered 1 through 3, 7, and 8); and

c. The date the staff had direct contact (personnel files numbered 1 through 8 and 10).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure staff files meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates a staff file includes all required components.

10. Citation: Minnesota Variance, section R2960V.16, subparts 2, items A and B, and 6.

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

a. Documentation did not demonstrate the staff person received orientation to the following prior to direct contact (personnel files numbered 1 through 8 and 10):

1. The requirements in MN Statutes, sections 245A.65, subdivision 3, and 626.556, subdivisions 2, 3, and 7;

2. Resident rights as identified in part R2960V.04 and Minnesota Statutes, section 253B.04;

3. Emergency procedures for fires, inclement weather, missing persons, and residents’ behavioral and medical emergencies;

4. Resiliency and recovery concepts and principles;

5. Gender based needs;

6. Resident confidentiality; and

7. Training related to the specific activities and job functions that the staff person will be responsible to carry out, including documentation of the delivery of services;

b. Documentation did not demonstrate the staff person received orientation to the following within 30 calendar days of first providing direct contact services (personnel files numbered 1 through 8 and 10):

1. Facility policies and procedures;

2. The treatment needs of residents, including psychiatric disorders and co-occurring disorders; and

3. Best Practice service delivery including:

i. Trauma-informed care;

ii. Developmentally appropriate care;

iii. The characteristics and treatment of residents with special needs for substance abuse, obsessive compulsive disorder, and eating disorders; and

iv. Co-occurring disorders as defined by the population being served; and

c. Documentation of orientation and training did not include the following:

1. Amount of time the training was provided (personnel files numbered 1 through 8);

2. Names and credentials of the people who certified the completion of the training (personnel files numbered 1 through 3, 7, and 8); and

3. Credentials of the people who certified the completion of the training (personnel files numbered 4 through 6).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation and the documentation of training meets all applicable requirements. Within 30 days receipt of this order, submit a revised orientation training checklist that demonstrates compliance. Within 60 days receipt of this order, submit documentation demonstrating all staff have been trained on all policies and procedures required by the PRTF Variance.

Resident Files

11. Citation: Minnesota Variance, section R2960V.04, subpart 2, item A.

Violation: Two of two resident files reviewed for requirements governing resident rights (resident files numbered 1 and 3) did not meet requirements. Documentation of the resident’s receipt of basic rights information did not include that the license holder also explained the rights to the resident.

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

12. Citation: Minnesota Variance, section R2960V.07, subpart 1, items A and B.

Violation: Two of two resident files reviewed for requirements governing the individual plan of care did not meet requirements in the following ways:

a. The immediate needs assessment and preliminary plan of care did not contain specific measures to minimize indicated safety risks (resident file numbered 3);

b. The strategy interventions did not identify the staff who are responsible to deliver the interventions (resident files numbered 1 and 3);

c. There was no documentation to demonstrate an individual support plan was developed for individuals that display behaviors that may require the use of restraint or seclusion (resident files numbered 1 and 3);

d. The plan of care did not contain the resident and legal guardian’s signature to acknowledge their participation in the development and/or revisions of the plan of care (resident files numbered 1 and 3);

e. The plan of care did not contain the title of the mental health professional for a plan dated July 7, 2022 (resident file numbered 3); and

f. An updated plan of care did not contain the mental health professional’s signature for a review dated July 15, 2022 (resident file numbered 3).

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

13. Citation: Minnesota Variance, section R2960V.06, subpart 1, item C and R2960V.19, subpart 4.

Violation: Two of two resident files reviewed for requirements governing treatment services (resident files numbered 1 and 3) did not meet requirements. There was no documentation provided to demonstrate case coordination activities occurred.

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

14. Citation: Minnesota Variance, section R2960V.08, subparts 2, item A, 3, and 4, items A through C.

Violation: Two of two resident files reviewed for requirements governing healthcare services and medication did not meet requirements in the following ways:

a. There was no documentation to demonstrate a health screen was provided within 72 hours of admission (resident file numbered 1);

b. Medication reconciliation was not conducted upon admission (resident files numbered 1 and 3) and upon discharge (resident file numbered 3);

c. There was no documentation to demonstrate written or verbal authorization from the resident’s legal representative to administer medication was obtained (resident file numbered 3);

d. The medication administration record included blank entries and there was no notation to indicate if the medication was administered as prescribed (resident file numbered 3);

e. There was no documentation in the file to demonstrate the quantity of medications initially received from the pharmacy (resident file numbered 3); and

f. There was no documentation in the file to demonstrate that prescription medicine belonging to a resident was given to the resident’s parent or legal guardian upon the resident’s release (resident file numbered 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure health care services and medication reconciliation meets all applicable requirements.

15. Citation: Minnesota Variance, section R2960V.08, subpart 6, items B and C.

Violation: Two of two resident files reviewed for requirements governing psychotropic medication reviews did not meet requirements in the following ways (resident files numbered 1 and 3):

a. The file did not contain the prescribing practitioner’s documentation of the following required information:

1. A description in observable and measurable terms of the symptoms and behaviors the psychotropic medication is to alleviate; and

2. Data collection methods the license holder must use to monitor and measure changes in symptoms and behaviors that are to be alleviated by the psychotropic medication;

b. The file did not contain documentation to demonstrate that the prescribing practitioner conducted and documented psychotropic medication reviews weekly for the first month.

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

16. Citation: Minnesota Variance, section R2960V.08, subpart 7, item E, and 8.

Violation: Two of two resident files reviewed for requirements governing informed consent did not meet requirements in the following ways:

a. The license holder did not obtain informed consent prior to the administration of a psychotropic medication (resident files numbered 1 and 3) and an antipsychotic medication (resident file numbered 3);

b. Informed consent was not obtained by the license holder within 30 days to continue the use of psychotropic medication for a resident admitted with prescribed psychotropic medication (resident file numbered 3);

c. Informed consent documentation dated June 10, 2022 (resident file numbered 1) and September 6, 2022 (resident file numbered 3) did not contain the following required information:

1. The diagnosis for which the psychotropic medication was prescribed;

2. The pharmacological and non-pharmacological treatment options available and the course of the condition with and without the treatment options;

3. Specific information about the psychotropic medication to be used, including:

i. The generic and commonly known brand name;

ii. The route of administration;

iii. The estimated duration of therapy; and

iv. The proposed dose;

4. An explanation that consent may be refused or withdrawn at any time and that the consent is time-limited and automatically expires within 30 days for oral consent and yearly for written consent;

5. The names, addresses, and telephone numbers of appropriate professionals to contact if questions or concerns arise; and

6. The signature of resident acknowledging the following:

i. Prescribing practitioner or designee has talked about the medication with resident and/or the resident’s legal representative and answered questions; and

ii. The resident and resident’s legal representative has agreed to the medication and dosage.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the informed consent meets all applicable requirements. Within 30 days receipt of this order, submit a revised form or template to demonstrate compliance.

17. Citation: Minnesota Variance, section R2960V.11, subpart 2.

Violation: Two of two resident files reviewed for requirements governing the documentation of the use of restraint and seclusion did not meet requirements. The documentation did not demonstrate the following:

a. Why the supportive and less restrictive interventions failed or were found to be inappropriate on October 13, 2022 (resident file numbered 2) and on July 23, August 27, September 3, 15, 20, and 26, 2022 (resident file numbered 3); and

b. The types of interventions utilized including the type of physical holding used on July 31, September 3, 15, 20, and 26, 2022 (resident file numbered 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of use of restraint and seclusion meets all applicable requirements. Within 30 days receipt of this order, submit a revised form/template for the documentation of uses of restraints to demonstrate compliance.

18. Citation: Minnesota Variance, section R2960V.11, subpart 3, items A through D.

Violation: Two of two resident files reviewed for requirements governing debriefings for the use of restraint and seclusion did not meet requirements. The debriefing following the use of restraint did not meet requirements in the following ways:

a. There was no documentation to demonstrate that debriefing sessions were conducted within 24 hours of the use of restraints for incidents occurring on July 23 and 31, August 27, September 3, 15, 20, and 26, 2022 (resident file numbered 3);

b. There was no documentation to demonstrate the resident was offered the opportunity to have a legal representative or advocate participate in the debriefing following the use of restraints on October 13, 2022 (resident file numbered 2); and

c. The debriefing did not include an evaluation of the circumstances that caused injury to staff or a plan to prevent future injuries following incidents on July 31, September 15 and 20, 2022 (resident file numbered 3).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of debriefings meets all applicable requirements. Within 30 days receipt of this order, submit a revised debriefing form or template that demonstrates compliance.

19. Citation: Minnesota Variance, section R2960V.11, subpart 4.

Violation: Two of two resident files reviewed for requirements governing administrative reviews of restrictive procedures did not meet requirements in the following ways:

a. There was no documentation to demonstrate an administrative review was completed for the use of restrictive procedures (October 13, 2022, resident file numbered 2, and July 23 and 31, August 27, and September 3, 2022, resident file numbered 3);

b. The administrative review was not completed within three working days (September 20 and 26, 2022, resident file numbered 3);

c. The administrative review was not completed by someone other than the person who decided to impose the restraint, or that person’s immediate supervisor (September 15, 2022, resident file numbered 3);

d. Documentation did not identify that the resident or the resident's representative had an opportunity to present evidence and argument to the reviewer about why the procedure was unwarranted (September 15, 20, and 26, 2022, resident file numbered 3); and

e. The record of the administrative review (September 15, 20, and 26, 2022, resident file numbered 3) did not include the following required components:

1. If the required documentation was recorded;

2. If the restrictive procedure was used in accordance with the treatment plan;

3. An evaluation of whether the rule standards governing the use of restrictive procedures were met; and

4. Whether or not the staff who implemented the restrictive procedure were properly trained.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of administrative reviews meets all applicable requirements. Within 30 days receipt of this order, submit a revised form or template to demonstrate compliance.

20. Citation: Minnesota Variance, section R2960V.07, subpart 4.

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

a. A description of how the license holder conferred with other interested persons to review the issues involved in the decision to discharge before discharging a resident who has not reached their treatment plan goals;

b. Whether the license holder, treatment team, interested persons, and the resident could develop additional strategies to resolve the issues leading to the discharge, and to permit the resident an opportunity to continue to receive services; and

c. What alternatives were considered or attempted, if the review indicated the decision to discharge was warranted.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure a no eject discharge meets all applicable requirements. Within 30 days receipt of this order, submit no-eject documentation or a form/template to demonstrate compliance.

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.

Assisting with personal care: DHS Licensing recommends the license holder clearly define the level of personal care assistance that staff are permitted to provide to residents in a policy or procedure, and

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; 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 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

report_date: November 2, 2022

summary: CORRECTION ORDER

raw_content:
November 2, 2022

Scott Zeiter

3150 Shawnee Drive

Winchester, VA 22601

RE:  Report No. 202206991

Grafton Integrated Health Network Minnesota Psychiatric Residential Treatment

License No. 1109203

Dear Mr. Zeiter:

CORRECTION ORDER

An investigation of Grafton Integrated Health Network Minnesota Psychiatric Residential Treatment was completed regarding report number 202206991 which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegation concerned neglect. The disposition of the investigation report is maltreatment not determined. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

The following violation of state and (or) federal laws and rules was observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violation within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

Citation: Minnesota statues section 260E.06, subdivision 1, paragraph (a), states in part that a person who knows or has reason to believe that a child is being maltreated, as defined in section 260E.03, shall immediately report the information to the agency responsible for assessing or investigating the report.

Violation: On July 14, 2022, supervisory staff persons were made aware of an incident of possible maltreatment occurring at the facility. However, the Department of Human Services, Division of Licensing was not made aware of the incident until August 26, 2022.

Corrective Action Ordered: Correct immediately and on an ongoing basis maintain compliance with Minnesota 260E.

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Tina Christensen, at 651-431-6610.

If you believe this citation is in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

Sincerely,

Carla Harvieux, Investigator

Office of Inspector General

Licensing Division

651-431-6616

Enclosure

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

doc_type: Correction Order


facility_name: Greater Minneapolis Crisis Nursery

report_date: November 7, 2025

raw_content:
PUBLIC

Summary of Settlement Agreement

License Holder: Greater Minneapolis Crisis Nursery

License Number: 830983

Program Type: Children’s Residential Facility

Date of Licensing Action: November 7, 2025

Licensing Action Taken: Order to Pay a Fine

Action appealed and settlement agreement signed by Commissioner on: March 6, 2026

Terms of Settlement Agreement:

License Holder withdraws appeal. License Holder paid half the fine. The remaining half will be stayed for a period of two years from effective date of the Settlement Agreement and will be dismissed after the two-year stay has expired if there are no violations during the stay.

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


report_date: November 24, 2025

raw_content:
November 24, 2025

Mary Pat Lee, Authorized Agent

Greater Minneapolis Crisis Nursery

4544 4th Avenue South

Minneapolis, MN 55419

License Number 830983 CRF

CORRECTION ORDER

Dear Mary Pat Lee:

On September 3-5, 2025, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Greater Minneapolis Crisis Nursery located at 4544 4th Avenue South, Minneapolis, MN 55419. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Children’s Residential Facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, and shelter care services under Minnesota Rules, parts 2960.0510 through 2960.0530. 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.

Policies, Procedures and Practices

1. Violation: A copy of the resident rights was not posted at the staff workstation.

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

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the resident rights are posted and meet all applicable requirements. This violation was corrected during the licensing review. No further corrective action is required.

2. Violation: The physical environment was not maintained on a consistent, healthy basis. During an on-site licensing review, DHS Licensors observed walls in need of repair, mold, baseboard radiators with exposed heating elements, and leaking duct work and lights.

Rule Violated: Minnesota Rules, part 2960.0110, subpart 3, item A.

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same Rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the physical environment and equipment meets all applicable requirements. Within 30 days receipt of this order, submit a written response and photographs demonstrating that the mold has been mitigated, walls have been repaired, and baseboard radiator heating is not accessible by residents served.

3. Violation: The license holder’s response to 1 of 13 grievances reviewed did not meet requirements. There was no documentation to demonstrate the license holder responded to a grievance dated March 31, 2025.

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

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same rule.

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

4. Violation: The license holder did not meet requirements for crib safety in the following ways:

a. There was no documentation to demonstrate monthly crib inspections had been completed for calendar year 2023; and

b. The license holder was using a non-full-sized crib mattress that was significantly smaller than the frame of the non-full-sized crib, leaving a gap larger than one inch at the perimeter.

Rule Violated: Minnesota Statutes, section 245A.146, subdivision 4, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure compliance with crib safety requirements. The license holder did immediately dispose of the ill-fitting crib mattress.

Personnel

5. Violation: Three of fifteen personnel files reviewed for requirements governing medication assistance did not meet requirements (personnel files numbered 2, 4 and 8). There was no documentation to demonstrate the staff person was trained to administer medications.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication assistance training meets all applicable requirements. Within 30 days receipt of this order, submit the following:

· A revised health and hygiene services policy that includes training by a medically licensed person for facility staff responsible for medication assistance;

· Documentation identifying all staff who administer medications;

· Documentation demonstrating they have received the required training.

6. Violation: Thirteen of thirteen personnel files reviewed did not meet requirements governing the license holder’s compliance with an approved variance dated 12/4/2006 allowing unlicensed staff people to conduct health screens (personnel files numbered 1 through 13). There was no documentation to demonstrate the license holder complied with the variance condition that unlicensed staff people would be trained by a qualified health professional to conduct health screens.

Rule Violated: Minnesota Statute, section 245A.04, subdivision 9.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure compliance with approved variances. Within 30 days, submit documentation demonstrating all staff who conduct health screens have been trained by a qualified health professional.

7. Violation: Eight of eight personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways:

a. Orientation to cultural diversity and gender sensitivity, general and special needs and operational policies and procedures was completed late, after first contact with residents (personnel file numbered 1);

b. There was no documentation to demonstrate the following required training was completed:

i. General and special needs of residents served (personnel files numbered 11-15);

ii. Data practices and regulations (personnel files numbered 1, 11-15);

iii. Administration of screenings upon admission (personnel files numbered 1, 11-15);

iv. The use of time-outs (personnel files numbered 1, 11-15);

v. The drug and alcohol policy (personnel files numbered 9, 11 and 12); and

vi. Staff duties in implementing the program’s policies and procedures (personnel files numbered 1, 9-15); and

c. Documentation of training did not include the name of the entity providing the training (personnel files numbered 1, 9-15).

Statute and Rules Violated: Minnesota Statutes, section 245A.04, subdivisions 1, paragraph (c) and 14, paragraph (b); Minnesota Rules, parts 2960.0100, subpart 3, item A; 2960.0070, subpart 5 and 2960.0080, subpart 5, item D.

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance for personnel files numbered 1, 9-15.

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

a. The annual training on maltreatment of minors reporting requirements and definitions was completed late:

i. Calendar year 2023 (personnel file numbered 3);

ii. Calendar year 2025 (personnel files numbered 12 and 15);

b. There was no documentation to demonstrate the staff person received training on maltreatment of minors reporting requirements and definitions in 2023 (personnel file numbered 8);

c. There was no documentation to demonstrate the staff person was trained on the risk of sudden unexpected infant death (personnel files numbered 2 through 5, 8 and 15);

d. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 2 through 5, 8, 10 through 12, 14 and 15).

Statute and Rule Violated: Minnesota Statutes, sections 245A.66, subdivision 4; 245A.1444 and Minnesota Rules, part 2960.0080, subpart 14.

Repeat Violation: In a Correction Order that DHS issued on January 14, 2022, you were previously found in violation of this same statute and rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating the following:

· The staff persons identified above have reviewed the emergency plan.

· The staff persons identified above have been trained on the risk of sudden unexpected infant death.

Residents:

9. Violation: One resident file (resident file numbered 3) reviewed for requirements governing time out procedures did not meet requirements. Documentation of a time-out implemented on 7/5/2025 did not include information about the resident’s ability to maintain acceptable behavior after the time-out was not included in the documentation.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that time-outs/Separation procedures meet all applicable requirements. Within 30 days receipt of this order, submit documentation of a time-out procedure that demonstrates compliance.

10. Violation: One of three (resident file numbered 1) resident files reviewed for requirements governing discharge procedures did not meet requirements. The belongings inventory was not initialed by the parent upon receipt of belongings.

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

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

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Laura Huff

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

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

Questions

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

Sincerely,

Laura Huff, Licensor

Licensing Division

Office of Inspector General

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


raw_content:
November 7, 2025                  CERTIFIED MAIL

Mary Pat Lee, Authorized Agent

Greater Minneapolis Crisis Nursery

4544 4th Ave. S

Minneapolis, MN 55419

License Number: 830983 (CRF)

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATION(S)

Dear Mary Pat Lee:

The Department of Human Services (DHS) is ordering you to pay a fine of $2600 for 13 background study violations. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order based on your failure to comply with the following background study requirement(s):

Background Study Violations Determined on September 4, 2025:

1. As a result of a licensing review, a DHS licensor determined that the license holder did not remove staff persons who did not cooperate with the background study in the following ways:

· A background study was submitted by the license holder but the staff person did not provide fingerprints within the time required (SP1, SP2, SP3, SP4 and SP8) and

· A background study was submitted by the license holder but the staff person did not provide consent within the time required (SP5 and SP10).

Statute Violated: Minnesota Statutes, section 245C.09, subdivision 1

Fine: $1400 ($200 per violation)

Corrective Action Required: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C. In response to this violation, the license holder has received cleared background studies for SP1, SP4, SP5, SP8 and SP10. The study for SP2 has required more time and SP3 has since been terminated.

2. As a result of a licensing review, a DHS licensor determined that you did not initiate a background study under Minnesota Statute 245C.03 subdivision1 for one staff person (SP11) before they began working in a position allowing direct contact with, or access to, persons served by the program.

Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (h).

Fine: $200

Corrective Action Required: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C. The license holder initiated a background study in response to this violation on 9/8/2025 and received clearance for SP11 to work in this facility on 9/13/2025. Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C.

3. As a result of a licensing review, a DHS licensor determined that the license holder did not submit a background study request to DHS for an individual who previously had a cleared study that expired for the following (SP6, SP7, SP9, SP12 and SP13):

· SP6 began working in a position allowing direct contact with persons served by the program on 11/05/2012. However, the license holder had not initiated a background study on SP6 in NETStudy 2.0 at the time of the licensing review.

· SP7 began working in a position allowing direct contact with persons served by the program on 05/21/2011. However, the license holder had not initiated a background study on SP7 in NETStudy 2.0 at the time of the licensing review.

· SP9 began working in a position allowing direct contact with persons served by the program on 10/1/2015. However, the license holder had not initiated a background study on SP9 in NETStudy 2.0 at the time of the licensing review.

· SP12 began working in a position allowing direct contact with persons served by the program on 09/15/2004. However, the license holder had not initiated a background study on SP12 in NETStudy 2.0 at the time of the licensing review.

· SP13 began working in a position allowing direct contact with persons served by the program on 04/30/2008. However, the license holder had not initiated a background study on SP13 in NETStudy 2.0 at the time of the licensing review.

Statute Violated: Minnesota Statutes, section 245C.03, subdivision 1 and 245C.04, subdivision 1, paragraph (h).

Fine: $1000 ($200 per violation)

Corrective Action Required: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C.

Billing and Payment of the Fine

DHS will send you an invoice for the $2600 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.

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

Licensing Division

Attention: 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

Licensing Division

Attention: 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.justice4mn.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 background study violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

· The exception that allows a license holder who self-corrects a background study violation to avoid a fine does not apply when the license holder was cited for the same violation within the past 365 days, under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d).

· 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.

· 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/

doc_type: Notice of Violation


facility_name: Hawkins Home

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


facility_name: Hazelden Plymouth

raw_content:
April 24, 2024

Rachael Swanson, Authorized Agent

Hazelden Plymouth

15251 Pleasant Valley Rd., PO BOX 11, FO-1

Center City, MN 55012

License Number: 1038741

Report Number: 202308285

CORRECTION ORDER

Dear Rachael Swanson:

A licensing investigation of Hazelden Plymouth, located at 11505 36th Ave N., Plymouth, MN 55441, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, and chemical dependency services under Minnesota Rules, part 2960.0430 through 2960.0490. As a result of this licensing investigation 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.

1. Citation: Minnesota Statutes, section 245A.65, subdivision 2.

Violation: The license holder’s program abuse prevention plan (PAPP) did not meet requirements. The license holder’s Children’s Residential Facility was co-located to their licensed Detoxification Services and Substance Use Disorder Treatment programs, which were licensed to serve adults, and a Facility Abuse Prevention Plan addressed all three licensed programs:

a.  The PAPP did not include measures to limit the possibility of harmful substances being brought into the facility at admission or accessed by residents in shared public spaces, such as bathrooms, visiting areas, and the cafeteria; and

b.  The PAPP did not include measures providing more frequent supervision of children who display behaviors that pose an imminent risk of harm.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program abuse prevention plan (PAPP) meets all applicable requirements. Within 30 days receipt of this order, submit a revised program abuse prevention plan (PAPP) that meet requirements to demonstrate compliance.

2. Citation: Minnesota Rules, parts 2960.0160, subpart 2.

Violation: The resident (R1) file did not contain documentation demonstrating the license holder determined whether the resident is a danger to themselves or others.

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

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

Violation: The no-eject discharge documentation for a resident (R1) did not meet requirements. The documentation did not demonstrate that all identified persons of the resident’s treatment team were included to develop any additional strategies to resolve the issues leading to discharge to allow the resident an opportunity to continue receiving services from the license holder.

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

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

B.   Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

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

Sincerely,

Tina Christensen, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

651-431-6610

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


report_date: October 25, 2023

raw_content:
October 25, 2023                  CERTIFIED MAIL

Rachael Swanson, Authorized Agent

Hazelden Plymouth

15251 Pleasant Valley RD

PO Box 11 F0-1

Center City, MN 55012

License Number: 1038741 (CRF)

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATION

Dear Rachael Swanson:

The Department of Human Services (DHS) is ordering you to pay a fine of $2,200 for 11 background study violations. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order based on your failure to comply with the following background study requirement:

Background Study Violation Determined on August 21, 2023:

1. As a result of a licensing review a DHS licensor determined that you failed to request a background study for eleven staff persons before they began working in a position before an adult, regardless of whether or not the individual will have direct contact with persons began working in the facility or setting.

A staff person (SP) was hired and began working in a position with persons served by the program. At the time of the licensing review on August 21, 2023, the license holder had not submitted the required background study request to DHS for the following staff working in a children’s residential facility:

a. SP1 began a position working in the facility August 2, 2023;

b. SP2 began a position working in the facility October 24, 2022;

c. SP3 began a position working in the facility June 26, 2023;

d. SP4 began a position working in the facility October 17, 2022;

e. SP5 began a position working in the facility March 6, 2023;

f. SP6 began a position working in the facility May 23, 2022;

g. SP7 began a position working in the facility January 31, 2022;

h. SP8 began a position working in the facility June 5, 2023;

i. SP9 began a position working in the facility April 3, 2023;

j. SP10 began a position working in the facility June 11, 2018; and

k. SP11 began a position working in the facility February 27, 2023.

Statute Violated: Minnesota Statutes, , and 245C.04, subdivision 11.

Fine: $2,200 (eleven violations at $200 per violation)

Corrective Action Required: You must comply with background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance will be maintained in the future.

Billing and Payment of the Fine

DHS will send you an invoice for the $2,200 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 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

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 receive 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

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

· DHS may impose a $200 fine for each background study 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/


report_date: October 24, 2023

raw_content:
October 24, 2023

Rachael Swanson, Authorized Agent

Hazelden Plymouth

15251 Pleasant Valley RD

PO Box 11 F0-1

Center City, MN 55012

License Number: 1038741 (CRF)

CORRECTION ORDER

Dear Rachael Swanson,

On August 21 through 24, 2023 a licensing review of Hazelden Plymouth located at 11505 36th Ave N, Plymouth, Minnesota 55441 was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, group residential services under Minnesota Rules, 2960.0130 through 2960.0220, and chemical dependency 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.

Policies, Procedures, and Practices

1. Citation: Minnesota Statutes 245A.04, subdivision 14, paragraph (a) and Minnesota Rules, part 2960.0150, subpart 3, item G.

Violation: The license holder’s Staffing Plan does not identify how the direct care staff to resident supervision ratios required for CRF residents will be met.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the Staffing Plan meets all applicable requirements. Within 30 days receipt of this order, submit a revised Staffing Plan that meets all applicable requirements to demonstrate compliance.

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

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

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the treatment services provided meet all applicable requirements. Within 30 days receipt of this order, submit a Therapeutic Recreation plan that meets all applicable requirements to demonstrate compliance.

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

Violation: The license holder’s program evaluation did not meet requirements. An annual evaluation of the strengths and weaknesses of the program was not completed for calendar years 2021 and 2022.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

4. Citation: Minnesota Rules, part 2960.0080, subpart 17, item A.

Violation: The license holder’s reporting of critical incidents did not meet requirements. Twelve of fifty-six incidents reviewed met the definition of a critical incident and were not reported to DHS:

a. Eight incidents involved an ambulance transport to the hospital; and

b. Four incidents involved a police response to the program due to elopement.

The license holder also provides substance use disorder treatment services to youth under Minnesota Statutes, chapter 245G, in addition to Minnesota Rules, chapter 2960. Internal incident reports did not clearly identify which standards were applicable to each youth.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the reporting of Critical Incidents to DHS meets all applicable requirements. Within 30 days receipt of this order, submit an incident reporting policy outlining the program’s procedure to ensure the reporting of critical incidents for CRF residents to demonstrate compliance.

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

Violation: The license holder’s use of time-out did not meet requirements. Incident report documentation reviewed indicated the use of time-out was implemented on January 2, February 6, and February 26, 2023, and April 20 and August 29, 2022, and August 11, 2021.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the use of time-out meets all applicable requirements. Within 30 days receipt of this order, submit a policy outlining how time-out will be used to demonstrate compliance.

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

Violation: The license holder’s satisfaction survey did not meet requirements in the following ways:

a. The license holder did not attempt to survey the resident’s parents/guardians or referring agency regarding their satisfaction with services; and

b. The survey did not include the following required components:

1. Sleeping accommodations;

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

3. Support of the resident’s regular and special education, related services, and support for implementing the resident’s individual education plan;

4. Support of obtaining needed dental services identified in the resident’s screening and assessments or otherwise observed or reported by staff or other persons involved with the resident’s care; and

5. Support of family reintegration, if appropriate.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

Personnel Files

7. Citation: Minnesota Statutes, section 245A.041, subdivision 5.

Violation: Five of five personnel files reviewed for requirements governing documentation did not meet requirements. The first date the staff person began working in the facility or setting was not documented (personnel files numbered 1 through 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements.

8. Citation: Minnesota Statutes, section 245C.04, subdivision 7.

Violation: Four of nine personnel files reviewed for requirements governing background studies (personnel files numbered 6 through 9) did not meet requirements. A legal name change occurred during the staff person’s employment; however, the license holder had not yet initiated a new background study or notified the commissioner at the time of the licensing review.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

9. Citation: Minnesota Rules, parts 2960.0100, subpart 3, item A, and subpart 5.

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

a. Orientation to the following was not completed before having unsupervised contact with residents (personnel file numbered 4):

1. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment;

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

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

4. Operational policies and procedures of the license holder including the programs drug and alcohol policy; and

5. Data Practices, regulations, and issues; and

b. Orientation training was not documented with the date, number of hours, and the name of the entity who provided the training in each topic area (personnel files numbered 1, 3, and 4).

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

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

Violation: Four of five personnel files reviewed for requirements governing the emergency plan (personnel files numbered 1, 2, 4, and 5) did not meet requirements. The emergency plan was not reviewed with the staff person at least once every six months.

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

11. Citation: Minnesota Rules, parts 2960.0100, subpart 5 and 2960.0150, subpart 4, item B.

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

a. Ongoing training was not documented with the date, number of hours, and the name of the entity who provided the training in each topic area (personnel files numbered 2 and 5); and

b. The license holder did not demonstrate the staff person completed at least 24 hours of in-service training for calendar year 2022 (personnel file numbered 2).

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

Resident Files

12. Citation: Minnesota Rules, part 2960.0160, subpart 2, item A.

Violation: Three of three resident files reviewed for requirements governing admission criteria (resident files numbered 1 through 3) did not contain documentation of the license holder’s determination of whether the resident is a danger to themselves or others.

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

13. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A, B and C.

Violation: Two of three resident files reviewed for requirements governing admission screenings did not meet requirements. The following screens were not completed:

a. Education (resident file numbered 3); and

b. Cultural needs (resident file numbered 2).

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

14. Citation: Minnesota Rules, part 2960.0490, subparts 2 and 3, items B, C, and E.

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

a. The participation of others was not noted within each plan (resident files numbered 1 through 3);

b. A treatment goal was not developed for dimension three, in which a problem had been identified, for plans dated August 3, 2023 (resident file numbered 1) and March 23, 2023 (resident file numbered 2); and

c. Minimum outcomes to be met before the resident discharged were not included in the plan dated August 3, 2023 (resident file numbered 1).

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 January 29, 2021.

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

Violation: Two of three resident files reviewed for requirements governing the safe delivery of medicine (resident files numbered 1 and 3) did not meet requirements. The resident was administered over the counter medications before they were prescribed by a licensed prescriber.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

16. Citation: Minnesota Rules, parts 2960.0090, subpart 3 and 2960.0190, subpart 1, item C.

Violation: Two of two resident files reviewed for requirements governing discharge procedures (resident files numbered 2 and 3) did not meet requirements. The license holder’s discharge documentation did not demonstrate:

a. The discrepancies between the resident’s inventoried property turned over to the facility at admission and the property returned to the resident at discharge, along with the resolutions of the discrepancies; and

b. A written notice of discharge was provided to the resident and the residents parents, or legal guardian.

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

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

17. Citation: Minnesota Rules, part 2960.0190, subpart 1, items A and B.

Violation: Two of two resident files reviewed for requirements governing the transition services plan did not meet requirements in the following ways:

a. A transition services plan was not developed (resident file numbered 2);

b. Resources available in the community to meet the resident’s continued needs were not included for all needs identified (resident file numbered 3);

c. Recommendations for how the resident may deal with issues and potential challenges within the environment they were returning to were not included (resident file numbered 3);

d. The plan was not developed with input from the appropriate school district and the continued service provider identified (resident file numbered 3);

e. A copy of the plan was not provided to the continuing treatment service provider that the resident will attend (resident file numbered 3); and

f. The following elements were not included (resident file numbered 3):

1. Recreation and leisure;

2. Appropriate educational, vocational rehabilitation, or training services;

3. Description of the resident’s financial and employment status;

4. Health Services; and

5. Personal Safety Needs.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the transition services plan meets all applicable requirements. Within 30 days receipt of this order, submit a transition service plan for one resident to demonstrate compliance.

Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated January 29, 2021.

18. Citation: Minnesota Rules, part 2960.0190, subpart 2, items A and B.

Violation: Two of two resident files reviewed for requirements governing discharge documentation did not meet requirements. The discharge summary did not include:

a. The education services, including who provided them, that the resident received during their stay in the program (resident files numbered 2 and 3); and

b. The services, including education that were recommended in the resident’s treatment plan, but were not provided to the resident (resident file numbered 3).

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 January 29, 2021.

B. Recommendations

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

1. It is recommended that the license holder schedule a meeting with their Licensor to discuss variance requirements to address the following:

i. Group size; and

ii. Storage of prescription stock medication.

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

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


facility_name: Heartland Ranch, Inc.

report_date: November 21, 2025

raw_content:
November 21, 2025

Jeannie Thompson, Authorized Agent

Heartland Ranch, Inc.

185 Highway 9 NE

Benson, MN 56215

License Number: 1036870 (CRF)

CORRECTION ORDER

Dear Jeannie:

On November 6, 2025, a certification review of Heartland Ranch, Inc., located at 185 Highway 9 NE Benson, MN 56215, was conducted to determine compliance. This review was conducted to determine compliance with state and federal laws and rules governing the provision of The Family First Prevention Services Act under Minnesota Statues 245A.25. As a result of this certification review a Correction Order is being issued.

LICENSING VIOLATIONS

DHS determined that your program did not follow licensing rules and statutes, as described below.

Personnel

1. Violation: Three of three personnel files reviewed for requirements of orientation training did not meet requirements. There was no documentation to support that the staff received training on the following topics prior to having direct contact with a youth:

a. Concepts of trauma informed care and how to provide services to each youth according to those concepts (personnel files numbered 4, 5, and 6); and

b. Impacts of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences (personnel files numbered 4, 5, and 6).

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

Repeat Violation: In a Correction Order that DHS issued on June 7, 2023, you were previously found in violation of this same statute.

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

2. Violation: One of six personnel files reviewed for requirements of ongoing training did not meet requirements. There was not documentation to support that staff received training on the impacts of each youth’s gender and sexual orientation on the youth’s behavioral health and traumatic experiences for the calendar year 2025 (personnel file numbered 6).

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

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

Written Response Required

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

Submissions required as part of the corrective action ordered must be sent to your licensor by email at 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/


raw_content:
July 12, 2023

Jeannie Thompson

Heartland Ranch, Inc.

189 Highway 9 NE

Benson, MN 56215

License Number: 1036870 (CRF)

CORRECTION ORDER

Dear Jeannie Thompson,

On June 7, 2023, a certification review of Heartland Ranch, Inc, located at 189 Highway 9 NE, Benson, MN 56215, was conducted to determine compliance with state and federal laws and rules governing the provision of The Family First Prevention Services Act under Minnesota Statues 245A.25. As a result of this certification review a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.25, subdivision 8 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.25 and is hereby ordered by the Commissioner of Human Services.

Personnel Files

1. Citation: Minnesota Statutes, section 245A.25, subdivisions 3, paragraph (h) and 5, paragraph (f).

Violation: One of five personnel files reviewed for the requirements governing orientation (personnel file numbered 2) did not meet requirements. The file did not contain documentation the staff was trained on the following prior to direct contact:

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

b. Human trafficking training.

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

If you fail to correct the violations specified in the Correction Order within the prescribed timelines the Commissioner may rescind certification pursuant to Minnesota Statutes, section 245A.25, subdivision 9.

B. Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding this Correction Order, please contact Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF 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/