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August 12, 2022 CERTIFIED MAIL Jon Benson, Authorized Agent On-Belay House 115 Forestview LN N Plymouth, MN 55441 License Number: 800099 ORDER OF CONDITIONAL LICENSE Dear Jon Benson: The Department of Humans Services (DHS) is placing your license to provide Chemical Health Children’s Residential Treatment services (CRF) at 115 Forestview LN N, Plymouth, MN 55441 on conditional status for two years, beginning August 25, 2022. This order is based on your noncompliance with Children’s Residential Facility (CRF) licensing requirements. Details of our findings are provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On June 6 through 8, 2022, DHS licensors conducted a licensing review at your facility located at 115 Forestview Lane North, Plymouth, Minnesota, 55441. As a result of this licensing review, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, citing 33 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of children served by the program. Nature and Severity: o Failure to comply with background study requirements (violation numbered 1 through 2); o Failure to ensure the staff met required qualifications (violation numbered 3 and 4); o Failure to comply with discipline policy and procedure requirements (violation numbered 5); o Failure to comply with staffing ratio’s (violation numbered 6); o Failure to ensure the environment provides for the comfort, privacy, and dignity of residents and that it is kept in good repair and housekeeping and maintenance is operated on a consistent and healthy basis (violation numbered 7); o Failure to comply with health services requirements (citation number 8); o Failure to comply with maltreatment of vulnerable adults and minors reporting policies and procedures (violation numbered 9 through 11); o Failure to comply with staff orientation and annual training requirements (violation numbered 12 to 16); o Failure to comply with weekly supervision of an individual with a temporary permit from the Board of Behavioral Health and Therapy (violation numbered 17); and o Failure to comply with requirements for transition and discharging a resident (violation numbered 18 and 19). Chronicity: Your program received its license on February 4, 1980. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes the last four years: o Sixteen of the 33 violations are repeat violations similar to violations cited in the licensing review correction order June 16, 2020. o One of the 33 violations are repeat violations similar to violations cited in the Background Study fine order May 19, 2020. o Eight of the 33 violations are repeat violations similar to violations cited in the licensing review correction order March 6, 2018. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of children served in your care, your license to provide Children’s Residential Facility services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. 1. Violation: As a result of a licensing review, a DHS licensor determined that you failed to request background studies (BGS) for nine of twenty-five staff persons before they began working in positions allowing direct contact with residents, or before an adult, regardless of whether or not the individual will have direct contact with persons served by the children residential facility, began working in the facility or setting a. Staff person (SP4) began a position working in the facility which allowed direct contact with persons served by the program on August 10, 2021. However, the license holder did not submit a BGS study request to DHS for SP4 until August 12, 2021. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d) , except for BGS violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a BGS violation before the commissioner discovers the violation. A license holder who has previously exercised the provisions of this paragraph to avoid a fine for a BGS violation may not avoid a fine for a subsequent BGS violation unless at least 365 days have passed since the license holder self-corrected the earlier BGS violations.
b. Although the license holder exercised the provisions of Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d) for SP4 on August 12, 2021, at least 365 days have not passed since the license holder self-corrected a BGS violation; therefore, the following are BGS violations. At the time of the licensing review, June 6 through 8, 2022, it was determined that the license holder did not submit a background study before an adult, regardless of whether or not the individual will have direct contact with persons served by the children residential facility, begins working in the facility or setting for the following: 1) SP7 began a position working in the facility April 14, 2022; however, the license holder did not submit a BGS request until June 3, 2022; 2) SP8 began a position working in the facility January 20, 2022; however, the license holder did not submit a BGS request until June 2, 2022; 3) SP9 began a position working in the facility April 1, 2022; however, the license holder did not submit a BGS request until June 2, 2022; 4) SP10 began a position working in the facility August 30, 2021; however, the license holder did not submit a BGS request until June 3, 2022; 5) SP13 began a position working in the facility January 31, 2022; however, the license holder did not submit a BGS request until March 3, 2022; 6) SP14 began a position working in the facility May 21, 2022; however, the license holder did not submit a BGS request until June 3, 2022; 7) SP16 began a position working in the facility August 30, 2019; however, the license holder had not initiated a BGS. The license holder was given notice to immediately remove SP16 from working in the facility on June 6, 2022; 8) SP17 began a position working in the facility May 5, 2022; however, the license holder did not submit a BGS request until June 3, 2022; and 9) SP19 began a position working in the facility May 30, 2022; however, the license holder did not submit a BGS request until June 7, 2022. In addition, during the review, an administrative staff person (SP20) was unable to accurately describe the background study requirements for which they were responsible for. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g), 245C.04, subdivision 11; and 245A.07, subdivision 3, paragraph (d). Repeat Violation: In a Correction Order that DHS issued on May 19, 2020, you were previously found in violation of this same statute. 2. Violation: The license holder operates multiple licensed programs and failed to affiliate staff persons on all active background study rosters for programs that the staff persons were working in. a. A background study was submitted for SP6, SP8, SP11, SP12, and SP17 under license number 1038850; however, the staff persons identified were also working under license number 800099; and b. A background study was submitted for SP15 under license number 800098; however, the staff person identified was also working under license number 800099. Statute Violated: Minnesota Statutes, section 245C.07, paragraph (f). Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute. 3. Violation: The program director did not appear to know and understand the implications of Minnesota Rules, parts 2960.0010 to 2960.0710 and Minnesota Statutes, chapter 260E and section 626.557. During the licensing review, the program director (SP21) demonstrated a lack of knowledge and understanding of many licensing requirements identified above that govern the program, and often deferred to other administrators as having the better understanding. Rule Violated: Minnesota Rules, part 2960.0460, subpart 3. 4. Violation: Two of two files reviewed for alcohol and drug counselor qualifications did not demonstrate that the staff persons had an additional 30 hours of classroom instruction in adolescent development and 150 hours of supervised experience as an adolescent alcohol and drug counselor (SP1 and SP2). Rule Violated: Minnesota Rules, part 2960.0460, subpart 5, items B and C. 5. Violation: During the licensing review a DHS licensor determined, through resident interviews and interactions with administrative staff persons, that the license holder had been utilizing disciplinary practices that the license holder failed to describe in a policy, which is necessary to maintain compliance with licensing regulations. Practices not included in policy are the following: a. House Retreats/Restrictions, was described as requiring each youth to remain in their rooms and all programming stops for an extended amount of time while the staff conduct an internal investigation in response to a youth(s) behavior(s) that impact the milieu. During a resident interview, the resident relayed information that they were on house restrictions for an entire weekend; and b. Color System, was described as a type of behavior management system for identifying levels of consequences and privileges for the resident. DHS licensors observed a white board in the group room which displayed the use of this practice. Rule/Statute Violated: Minnesota Statutes 245A.04, subdivision 14, paragraph (a) and, and 2960.0080, subparts 4, items A, and 5, A. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute. 6. Violation: For the week reviewed, May 22, 2022 to May 28, 2022, for requirements governing staff ratios, the license holder failed to ensure at least one direct care staff was present for every twelve residents during awake hours on the following dates and shifts: a. On May 25, 2022, one staff scheduled for the morning shift with a census of 15 residents; b. On May 27, 2022, one staff scheduled for the morning shift with a census of 15 residents; and c. On May 28, 2022, one staff scheduled for the evening shift with a census of 15 residents. Rule Violated: Minnesota Rules part, 2960.0150, subpart 3, item G. 7. Violation: The license holder failed to ensure the physical environment met the needs of the residents and was kept in good repair: a. The physical environment did not provide for the comfort and dignity of residents as it contained minimal amounts of furniture and comfortable seating options in communal areas; b. Storage and housekeeping were not operated on a consistent and healthy basis. A DHS licensor observed mold in showers and unclean shower stalls, piles of clothes in the hallway on the floor, a mattress, bedframe, and broken laundry basket stored in the back hallway. In addition, the utility/storage room contained piles of garbage in corners; and c. The fixtures were not kept in good repair. A DHS licensor observed broken, stained, and worn out toilet seats, a broken counter top in the kitchen, rust on the bathroom stalls, and a brown substance in the downstairs shower. Rule Violated: Minnesota Rules, parts 2960.0110, subparts 2 and 3, items A and D, and 2960.0200, item A. 8. Violation: Three of three resident files reviewed for requirements governing health services did not meet requirements in the following ways: a. The license holder did not complete medication verification upon admission for a resident who admitted with prescribed medications (R1); b. The medication verification did not include the symptoms that the medication will alleviate and the symptoms that would warrant consultation with the physician (R3 and R5); and c. Documentation to demonstrate the record keeping of the quantity of medications initially received from the pharmacy was not provided (R1 and R5). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D and E. 9. Violation: The vulnerable adult and maltreatment of minors reporting policies and procedures did not meet requirements in the following ways: a. The vulnerable adult reporting policy did not include: 1) The secondary person or position to whom internal reports may be made and is responsible for forwarding internal reports to the common entry point; and 2) The internal review must include an evaluation that the policies and procedures were adequate and if there was a need for additional staff training; b. The maltreatment of minors reporting policy did not include: 1) The correct information for where the mandated reporter is to immediately report the information to. In addition, the policy indicates to report to the common entry point which is the reporting center for vulnerable adults, not minors; 2) A person mandated to report child maltreatment occurring within a licensed facility shall report the information the Department of Human Services; 3) The accurate use of referencing children or minors where appropriate versus referencing vulnerable adults; 4) The secondary person or position who will ensure internal reviews are completed; and 5) Consistent processes for meeting requirements. The policy contains contradictory and duplicate processes; and c. The license holder did not review policies and procedures about maltreatment at least annually and revise the policies if the maltreatment laws change, as evidenced by not referencing Minnesota Statute 260E, Maltreatment of Minors Statute and Rule Violated: Minnesota Statues, sections 260E.06, subdivision 1; 260E.11, subdivision 1; 245A.65, subdivision 1, paragraph (b); and 245A.66, subdivision 1; and Minnesota Rules, part, 2960.0080, subpart 17, item D. Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 10. Violation: The license holder’s internal reviews of alleged or suspected maltreatment of minors, for incidents dated January 25, 2021, and February 17, 2022, did not meet requirements in the following ways: a. The documentation for the incident dated January 25, 2021, did not include: 1) A date to determine the internal review was completed within 30 days; 2) An evaluation of whether: i. The policies and procedures were followed; ii. The policies and procedures were adequate; iii. The reported event is similar to past events with the children or the services involved; and 3) Documentation that the internal review was completed; and b. There was no documentation of an internal review complete for the incident dated February 17, 2022. Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1. 11. Violation: The program abuse prevention plan did not meet requirements in the following ways: a. The need for specialized programs of care for clients was not addressed in the program abuse prevention plan; and b. There was no documentation to demonstrate the plan was reviewed annually by the license holder’s governing body or delegated representative in calendar year 2021. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 12. Violation: Three of three personnel files reviewed for requirements governing orientation training did not meet requirements. The license holder did not provide the following training: a. Before the staff person had unsupervised contact with residents: 1) Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment (SP1); 2) Cultural diversity, gender and cultural sensitivity, culturally specific services, information about discrimination and racial bias issues, general and special needs, including disability needs of residents and families served prior to direct contact with residents (SP1); 3) Maltreatment of minors reporting requirements (SP1); 4) Operational policies and procedures of the license holder, including the program’s drug and alcohol policy (SP1 and SP7); 5) Data practices regulations and issues (SP1); and b. Within 72 hours of first providing direct contact services: 1) HIV/Minimum Standards orientation training (SP1); and 2) Vulnerable adult maltreatment reporting requirements, the program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (SP1); c. Before conducting screens, training on the administration of screenings upon admission of residents (SP3); and d. An overnight staff file did not contain documentation of their knowledge of and ability to perform basic first aid procedures, including cardiopulmonary resuscitation and first aid for seizures, trauma, and fainting (SP7). Statute and Rule Violated: Minnesota Statutes, sections 245A.65, subdivision 3 and 245A.19, paragraph (a), and Minnesota Rules, parts 2960.0460, subpart 8, item A, 2960.0100, subpart 3, item A, and 2960.0070, subpart 5.
Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute. 13. Violation: Seven of seven personnel files reviewed for requirements governing the documentation of annual and orientation training occurring did not meet requirements (SP1 through SP7). Documentation from January 2021 through June 5, 2022, did not consistently include the date, number of hours, and the name of the entity that provided the training in each topic area. Rule Violated: Minnesota Rules, part 2960.0100, subpart 5 Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018
14. Violation: Four of four personnel files reviewed for requirements governing ongoing training did not meet requirements (SP2, SP3, SP5, and SP6). The staff person did not receive the following annual training: a. a. Vulnerable adults maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; b. The license holders program abuse prevention plans; and c. Internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. Statute and Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, part 2960.0100, subpart 3, item A. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute. 15. Violation: Four of four personnel files reviewed for requirements governing the emergency plan did not meet requirements (SP2, SP3, SP5, and SP6). The license holder did not review the facilities emergency plan once at least every six months for calendar year 2021. Rule Violated: Minnesota Rules, part 2960.0080, subpart 14. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020, you were previously found in violation of this same statute. 16. Violation: Four of four personnel files reviewed for requirements governing in-service training hours did not meet requirements in the following ways: a. The full-time staff did not complete at least 24 hours of training for calendar year 2021 (SP2 and SP6); and b. The part-time direct care staff did not have at least one hour of training per fifty hours worked for calendar year 2021 (SP3 and SP5). Rule Violated: Minnesota Rules, part 2960.0150, subpart 4, items B and D. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute.
17. Violation: One personnel file reviewed for requirements governing supervision of an individual with a temporary permit (SP1) did not meet requirements. The file did not contain documentation that the staff person received supervision related to clinical practices at least weekly by an LADC for the weeks of April 18, 2022, May 16, 2022, May 23, 2022, and May 30, 2022. Rule Violation: Minnesota Rules, part 2960.0460, subpart 6a, item A. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute. 18. Violation: Two of two resident files reviewed for requirements governing no eject policy (R4 and R5) did not meet requirements in the following ways: a. The license holder did not confer with other interested persons to review the issues involved in the decision to discharge the resident; and b. The license holder determined whether the license holder, treatment team, interested persons and the resident could develop additional strategies to resolve the issues leading to the discharge and permit the resident an opportunity to continue to receive services from the license holder. Rule Violated: Minnesota Rules, part 2960.0090, subpart 2. Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 19. Violation: Two of two resident files reviewed governing transition services plans and discharge documentation did not meet requirements in the following ways: a. The plan did not recommend ways to meet the resident's needs and identify resources available in the community to address the resident's continuing needs after release from the facility (R3 and R6); b. The plan did not consider the environment the resident will return and recommend how the resident may deal with issues and potential challenges within the environment (R3 and R6); c. The following elements of the plan were not included for the following resident files: 1) Budget plan, health services, and leisure activities (R3); and 2) Vocational services, rehabilitation services, financial status, and health services (R6); d. Discharge documentation did not identify which services, including education, were provided directly or indirectly to the resident and who provided the services (R3); and e. Discharge documentation did not identify the services, including education, that were recommended in the resident's case plan or treatment plan but were not provided to the resident (R3 and R6). Rule Violated: Minnesota Rules 2960.0190, subparts 1, items A and B, and 2, items A and B. 20. Violation: Two of four resident files reviewed for requirements governing admission criteria (R2 and R3) did not meet requirements. Before or at admission of a resident, the license holder did not document whether the program was able to meet the resident’s cultural, emotional, educational, mental health, and physical needs. Rule Violated: Minnesota Rules 2960.0160, subpart 2, C. 21. Violation: Three of four resident files reviewed for requirements governing the inventory of personal property did not meet requirements. a. The inventory only contained one staff signature and no resident signature, therefore the license holder did not sign the inventory upon admission by two staff if the resident refused to sign (R1 and R5); b. The inventory was not signed by the license holder or the resident upon admission (R2); and c. The discharge inventory was not signed by the license holder or the resident (R5). Rule Violated: Minnesota Rules, parts 2960.0070, subpart 4, and 2960.0090, subpart 3. Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 22. Violation: One of two resident files for persons eighteen and older was reviewed for requirements governing the assessment of risk and development and review of the individual abuse prevention plan (IAPP) and did not meet requirements. The IAPP was not reviewed during each service plan review from creation to discharge (R6). Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 23. Violation: Two of four resident files reviewed for requirements governing the initial services plan (ISP) (R1 and R3) did not meet requirements. The ISP did not include the issues that are to be addressed in the first treatment sessions. Rule Violated: Minnesota Rules, part 2960.0485. 24. Violation: Four of five resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. The health screening did not include the most recent physician and clinic name, address and telephone number (R1 and R2); and b. No documentation of a mental health screen completed within six working days of admission (R1 through R3, and R5). Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, item C. 25. Violation: Four of four resident files reviewed for requirements governing treatment plans and treatment services did not meet requirements in the following ways: a. The frequency of the intervention was not identified for every goal/intervention in the treatment plan (R2, R3, and R5); b. The treatment plan was not reviewed at least every two weeks from November 26, 2021 through December 13, 2021 (R5); c. There was no documentation of weekly reviews of services to indicate the type and amount of each service the resident received that week and whether the services have had the desired impact during the following time frames: 1) Admission to present time of licensing review (R1 and R2); 2) Admission to discharge (R3 and R5); d. Documentation was not provided to determine if therapeutic recreation was provided for the following time frames: 1) Admission to January 2022 (R3); and 2) Admission to discharge (R5). Rule Violated: Minnesota Rules, parts 2960.0490, subparts 3, item C, 4, and 5, and 2960.0450, subpart 2, item D. Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 26. Violation: The license holder did not provide DHS with the annual documentation of their efforts to contact and seek information from the cultural or racial community groups related to the resident’s cultural or racial minority backgrounds they serve to provide opportunities for the resident’s to associate with similar cultural and racial backgrounds. Rule Violated: Minnesota Rules, part 2960.0100, subpart 2. 27. Violation: The license holder failed to provide therapeutic recreation treatment services that are led by, directed by, or provided according to a plan developed by a qualified alcohol and drug counselor. Rule Violated: Minnesota Rules, part 2960.0450, subpart 2, item D. 28. Violation: The license holder did not develop an annual training plan for employees that was relevant to the population being served. Rule Violated: Minnesota Rules part 2960.0150, subpart 4. 29. Violation: A review of incident reports for November 2021, December 2021, and June 2021 identified the following incidents met the definition of a critical incident and were not reported to the commissioner of human services as required: a. An incident occurred on November 30, 2021 involving a resident running from the program and returned by police transport on December 1, 2021; and b. An incident occurred on June 20, 2021 involving the fire department responding to a call and clearance of the building. Rule Violated: Minnesota Rules, part 2960.0080, subpart 17, item A. 30. Violation: The license holder failed to provide a written response to grievances within five business days of receipt and document the findings and actions taken by the license holder as required. A review of grievances submitted from September 2020 to May 2022 did not include the following: a. A grievance dated January 30, 2021 did not document the findings and actions taken by the license holder; and b. Grievances dated April 30, 2021 (x3), May 2, 8, and 28, 2021, did not contain a response nor was there documentation of the findings and actions taken by the license holder. Rule Violated: Minnesota Rules, part 2960.0080, subpart 18. 31. Violation: The license holder’s satisfaction surveys did not contain an assessment of the following components: a. Recreation, food, and sleeping accommodations provided to the resident; b. The accuracy, usefulness, and appropriateness of the screening and assessment of the resident's physical and emotional well-being and functioning; and c. Provisions for the resident’s safety. Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, item A. 32. Violation: The outcome measures, evaluations and community advising did not meet requirements in the following ways: a. The license holder did not complete an annual evaluation of the programs strengths and weaknesses in calendar year 2020 and 2021 using the following performance indicators: 1) Accidents; 2) The use of restrictive procedures; 3) Grievances; 4) Adverse findings, allegations of maltreatment under Minnesota Statutes, section 626.556, citations and legal actions against the license holder; 5) Information from the programs outcomes and outcome measures; 6) Results of resident and family satisfaction surveys; and 7) Critical incidents; and b. The license holder did not meet annually with their board of directors or advisory committee nor with the community leaders representing the area where the facility is located for calendar years 2020 and 2021. The license holder reported meeting with the local police department, though did not provide documentation of those meeting notes. Rule Violation: Minnesota Rules, part 2960.0060, subparts 3, item A and 6. Repeat Violation: In a Correction Order that DHS issued on June 16, 2020 you were previously found in violation of this same statute. 33. Violation: The license holders plan for transfer of clients and records upon closure did not meet requirements. The license holder did not have a plan for transfer of clients and records upon closure; therefore, the controlling individual did not annually review and sign the plan for transfer of clients and records upon closure for calendar year 2021. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a paragraphs (b) and (c). Repeat Violation: The license holder was previously found in violation of this same statute in Correction Orders that DHS issued on: · June 16, 2020 · March 6, 2018 License holders determined to have a background study violation are required to pay a $200 fine for each violation. Because license revocation is a more severe sanction against your license, DHS is not imposing this fine. Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this order, you must notify current residents and all parties who refer residents to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new residents and referral sources the license is on conditional status before they begin receiving treatment services. The notification to new residents must specify the length of time of the conditional status of your license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. A copy of the notice with resident and legal representative(s) signature must be maintained in the resident file. Within 30 days of receipt of this order, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice. 2. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on rule requirements for children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490. Individuals required to attend are the Program Director, Compliance Office, LADC Supervisor, RN, and Chief Operating Officer of On-Belay must attend the training offered by DHS Licensing. Training must be completed within 45 days of receipt of this order. 3. Within 14 days of receipt of this order, you must contact Paula Halverson DHS Licensing Mental Health, Substance Use Disorder and Children’s Residential Facilities Unit Manager to schedule a training on statute requirements for Background Studies under Minnesota Statute, chapter 245C. Individuals required to attend is your designated N2study sensitive information person and authorized agent. Training must be completed within 45 days of receipt of this order. 4. Within 14 days of receipt of this order, you must employ a staff person for the position of Compliance Officer. This staff person may not also hold the positons of Program Director or Alcohol and Drug Counselor Supervisor and must be consider at least 0.5 full-time Compliance Officer for license number 800099. 5. Within 30 days of receipt of this order, you must develop a self-monitoring tool and plan that assures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following: a. Name and titles of those responsible to carry out duties within the plan; and b. Procedure that includes a sample review of resident records, personnel files, required treatment services, treatment plans and reviews, medication administration records and medication verifications, incident reports, grievances, and monitoring of the implementation of policies and procedures on a monthly basis. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on November 12, 2022, February 12, 2023, May 12, 2023, and August 12, 2023 or until otherwise determined by DHS Licensing. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all Minnesota Rule 2960, children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Children’s Residential Facilities with Chemical Dependency services are required to follow Minnesota licensed children's group residential facilities under Minnesota Rules, 2960.0010 through 2960.0220, and chemical dependency services under Minnesota Rules, 2960.0430 through 2960.0490, · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Katie Leuer, Supervisor, at 651-431-6259.
Sincerely, Paula Halverson, Unit Manager Licensing Division Office of Inspector General
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