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October 7, 2022 Michelle Murray, Authorized Agent Nexus Gerard Family Healing 505 Highway 169 North Plymouth, Minnesota, 55441-6447 License Number: 831080 (CRF) Report Number: 202201129 CORRECTION ORDER Dear Michelle Murray: On June 27 and June 28, 2022, the Department of Human Services (DHS) conducted a modified licensing review and licensing investigation at your facility located at 1111 28th Street Northeast, Austin, Minnesota, 55912-6410. The modified licensing review and licensing investigation were 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 facilities under Minnesota Rules, 2960.0130 through 2960.0220, and residential mental health treatment under Minnesota Rules, 2960.0580 through 2960.0700, and restrictive techniques standards under Minnesota Rules, part 2960.0710 (Rule CRF). As a result of this modified licensing review and licensing investigation, a correction order is being issued. 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 modified licensing review and licensing investigation. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Postings 1. Citation: Minnesota Rules, part 2960.0050, subpart 3, item D. Violation: A copy of the resident’s rights was not posted in the staff work station of each unit. Corrective Action Ordered: This violation was corrected during the licensing review, no further corrective action is required. Policies and Practices 2. Citation: Minnesota Rules, part 2960.0160, subpart 4, item A. Violation: The license holder’s practice of giving required information about facility rules to residents did not meet requirements in the following ways: a. The rules provided to residents upon admission did not include all of the rules and consequences used at the program. Daily shift reports documented use of “room programming” that was not included in the information provided to residents; and b. The rules and consequences in resident handbooks varied by each unit and were inconsistent with those identified in the policy and procedure manual. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the facility rules provided to residents at admission meet all applicable requirements. Within 30 days receipt of this order, submit revised resident handbooks and a revised policy that demonstrates compliance. 3. Citation: Minnesota Rules, part 2960.0050, subpart 3, item A. Violation: The license holder’s practice of providing basic rights information to residents within 24 hours of admission did not meet requirements. A copy of the basic rights information was not provided to residents. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that a copy of resident rights provided to the resident meets all applicable requirements. Within 30 days receipt of this order, submit documentation that demonstrates compliance. Personnel Files 4. Citation: Minnesota Statutes, section 245A.041, subdivision 5. Violation: Six of six personnel files reviewed for requirements governing background studies (personnel file numbered 1, 2, 5 and 14 through 16) did not meet requirements. There was no documentation of the first date the staff person began working in the licensing holder’s facility. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that background study documentation meets all requirements. 5. Citation: Minnesota Rules, part 2960.0080, subpart 14. Violation: Eleven of thirteen personnel files reviewed for requirements governing ongoing training (personnel files numbered 1, 2, 6 through 10, 11 through 13 and 16) did not meet requirements. The files did not contain documentation to demonstrate that staff received ongoing training on emergency procedures at least every six months in 2021 and 2022. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of ongoing training meets all requirements. Within 30 days receipt of this order, submit documentation that staff identified above, who currently work for Nexus Gerard, have received emergency procedure training. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. Resident Files 6. Citation: Minnesota Rules, part 2960.0070, subpart 4. Violation: Five of five resident files reviewed for requirements governing admission procedures (resident files numbered 1 through 3, 5 and 6) did not meet requirements. Documentation contained the resident signature on a “Personal Property Waiver” that did not include the inventory of the resident’s property; the inventory was maintained in a separate electronic file. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meet all applicable requirements. 7. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A through C. Violation: Six of six resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. The health screenings were not completed within 24 hours and did not include the following required components: 1. The resident’s current medications (resident files numbered 2 and 7); 2. The most recent physician’s and clinic’s name (resident files numbered 1 and 7), and address and telephone number (resident file numbered 1 through 3, 5 through 7); and b. There was no documentation to show that the screening for sexually abusive behavior was completed (resident file numbered 1), or that a risk management plan was created (resident file numbered 5 and 6); and c. There was no documentation to show the degree to which the family desires to be involved during the residents stay at the facility (resident file numbered 6). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that admission screenings meet all applicable requirements. Within 30 days, submit documentation for two resident admission screenings that demonstrate compliance. 8. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D and subpart 14. Violation: Three of five resident files reviewed for requirements governing program services did not meet requirements in the following ways: a. There was no documentation to demonstrate chemical health education was provided to a resident who has had a problem related to inappropriate chemical use (resident file numbered 6); and b. Emergency plans were not reviewed with residents at least once every six months (resident file numbered 2, 5, and 6). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that program services meet all applicable requirements. 9. Citation: Minnesota Rules, parts 2960.0600, item A, and 2960.0620, subpart 1, items A and B. Violation: Six of six resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The treatment plan was not completed within 10 working days of admission (resident file numbered 7); and b. The plan was not based on a diagnostic assessment (DA); a DA was not completed (resident file numbered 7); and c. The treatment plan did not include the following required components: 1. A schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 3, 5 and 6); and 2. The use of psychotropic medication (resident file numbered 3); and 3. A description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident file numbered 2); and 4. The data collection methods used to monitor and measure changes in the symptoms and behaviors that are alleviated by the psychotropic medication (resident files numbered 1 and 2). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 2, item b. Minnesota Rule, part 2960.0080, subpart 5, item D. Violation: Three of four resident files reviewed for requirements governing service plan reviews did not meet requirements in the following ways: a. There was no documentation to demonstrate that the interdisciplinary team reviewed and evaluated the individual abuse prevention plan (IAPP) as part of the service plan review (resident file numbered 6); and b. There was no documentation to demonstrate the treatment team reviewed the use of time out as a part of the individual’s treatment plan (resident file numbered 1, 5, and 6). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that service plan reviews meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. 11. Citation: Minnesota Rules, part 2960.0620, subparts 2, and 5, items A, B and D. Violation: Four of four resident files reviewed for requirements governing psychotropic medication monitoring did not meet requirements. The resident file did not include documentation of the following: a. Weekly monitoring for side effects, for the first six weeks after a resident is admitted with psychotropic medication (resident file numbered 6); and b. A monthly medication review for the first six months of taking a psychotropic medication (resident file numbered 5); and c. A quarterly medication review (resident file numbered 1, 2, 5, and 6); and d. There was no documentation of data collected since the last review (resident file numbered 1); and e. The status of the resident’s goals in the individual treatment plan (resident file numbered 1, 2, 5, and 6). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication monitoring meets all requirements. 12. Citation: Minnesota Rules, part 2960.0620, subpart 7, item A. Violation: Five of five resident files reviewed for requirements governing informed consent did not meet requirements (resident files numbered 1, 3, 5, and 6). Informed consent documentation did not include the following required components: a. The diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed; and b. The pharmacological and nonpharmacological treatment options available and the course of the condition with and without treatment options. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding informed consent meet all requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. 13. Citation: Minnesota Rules, 2960.0080, subpart 5, item D. Violation: Three of three resident files reviewed for requirements governing time out procedures (resident files numbered 1, 5, and 6) did not meet requirements. Documentation reviewed in milieu notes and shift reports referenced multiple instances where time-out was used, but the documentation required following the use of a time-out was not completed. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding time out procedures meet all requirements. Within 30 days receipt of this order, submit documentation demonstrating all staff persons have been re-trained on the use of time-out and any related policies or procedures. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. 14. Citation: Minnesota Rules, 2960.0710, subpart 10. Violation: Two of five resident files reviewed for requirements governing the administrative review of restrictive procedures (resident files numbered 5 and 7) did not meet requirements. The administrative review must be completed by someone other than the person who decided to impose the restrictive procedure or that person’s immediate supervisor. The administrative review completed did not identify who completed the administrative review. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding administrative reviews meet all requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. 15. Citation: Minnesota Rules, 2960.0090, subpart 1, items B and C, subpart 2 and 3. Violation: Five of five resident files reviewed for requirements governing discharge procedures did not meet requirements in the following ways: a. For the discharge of a resident who did not reach their treatment plan goals, documentation did not include: 1. How the license holder conferred with other interested person(s) to review the issues involved in the decision (resident file numbered 8); and 2. The involvement of interested parties in discussing the issues leading to the discharge and determining if additional strategies could permit the resident to stay in the program (resident files numbered 4 and 8); and 3. If the review indicated that the decision to discharge was warranted, the reasons for it and the alternatives considered or attempted (resident file numbered 8); and b. The resident file did not contain a signed receipt of personal property (resident files numbered 3, 4, and 8). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements governing No Eject and discharge procedures meet all requirements. Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020. 16. Citation: Minnesota Rules, part 2960.0190, subpart 1, item A. Violation: Two of two resident files reviewed for requirements governing transition services plans (resident files numbered 7 and 8) did not meet requirements. There was no documentation to demonstrate that a transition services plan was completed prior to the residents release from the program. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements governing transition services plans meet all requirements. 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 DHS Licensing at: 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services YOUR 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 Maddy Gilbertson, Senior Licensor at 651-448-3583, as soon as possible.
Licensing Division Office of Inspector General PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer http://www.dhs.state.mn.us/licensing
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