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October 12, 2022 Eric Vagle, Authorized Agent Minnesota Adult & Teen Challenge – Lakeside Academy 740 East 24th Street Minneapolis, MN 55404 License Number: 1078609 (CRF) Investigation Report Number: 202110234 Dear Eric Vagle: On July 5, 2022, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of all three citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on June 10, 2022.
Citation 1: The correction order stated the license holder did not meet requirements of ensuring basic rights in the following ways: a. The license holder assigned the residents (R1 through R21) work that was not consistent with the resident’s case plan. The license holder assigned residents with “service hours” as a consequence for undesirable behaviors. “Service hours” were assigned as a designated amount of time in hours to complete various tasks. The license holder’s Community and Service Hours List identified that “service hours” tasks included various types of physical labor/work such as cleaning various areas of the facility, washing dishes, serving meals, collecting garbage, maintaining facility grounds and assisting in the barn by feeding and cleaning up after the animals and restocking hay bales. While the license holder defined “service tasks” as restorative assignments meant for therapeutic purposes, the tasks assigned were not always related to the behavior the intervention was meant to address, and the interventions were not included in the treatment plan. b. As a consequence, the amount of hours assigned for the type of behavior are not proportionate and reasonable. A Shift Facility Log dated August 2, 2201, documents that for being disruptive past room time, one resident (R14) earned 1 service hour when a second resident (R15) earned 4 service hours. The license holder’s Behavior and Corrective Action LASH 330 policy indicates that a resident can earn 1 service hour for cussing/swearing and that the amount of service hours assigned for each behavior increases as the resident advances in their treatment level. For example, residents on level 2 will be assigned 2 service hours and residents on level 4 will be assigned 4 service hours for the same behavior. c. Additionally, the license holder’s Service Hours policies and practices and the Community Hours policies and practices are not clearly distinguishable. They have an alikeness that creates confusion and a level of contradiction. One is a consequence while the other is a requirement to complete treatment, yet both entail completion of assigned amounts of time for alike tasks. Request for Reconsideration. The program submitted information and documentation to support the belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder asserted it did not fail to ensure the basic rights of residents and that service tasks are not required to be related to the behavior the intervention was meant to address.
Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0050, subpart 1, item O, a resident has basic rights, including, but not limited to, if applicable, the rights stated in Minnesota Statutes, sections 144.651 and 253B.03. The license holder must ensure the rights in items A to R are protected. Pursuant to Minnesota Rules, part 2960.0020, subpart 31, “discipline” means the use of reasonable, age-appropriate consequences designed to modify and correct behavior according to a rule or system of rules governing conduct. With regard to violation a, because the program provides substance use treatment services, Minnesota Statutes, section 144.651 applies. That section specifies in subdivision 23 that residents should not perform labor or services for the facility unless those activities are included for therapeutic purposes and appropriately goal-related in their individual medical record. The license holder assigned tasks that included washing dishes, serving meals, collecting garbage and cleaning up after animals which are labor and services for the facility. Those specific tasks were not consistently assigned for therapeutic purposes and were assigned as a consequence that as not consistent with the resident’s case plan. As a result, it is appropriate to affirm the citation. With regard to violation b, “discipline” is defined as the use of consequences which are “reasonable.” Reasonable is commonly defined to mean fair and sensible or appropriate. The violation was issued because facility documentation indicated that when two residents engaged in the same behavior (being disruptive past room time), one of the residents earned four service hours while the other only earned one. Facility policy indicated that residents on different treatment levels earned different amounts of service hours for the same behavior. As a result, the use of consequences was not reasonable because residents did not receive the same consequences for the same behavior, and it is appropriate to affirm the violation. There is therefore sufficient evidence to support the citation as to violations a and b, and those violations are affirmed. With regard to violation c, information submitted with the reconsideration request and further review shows the license holder was in compliance with the requirements. As a result, it is appropriate to rescind violation c. Citation 2: The correction order stated that the license holder’s policy on facility rules did not meet requirements, as the license holder failed to communicate in writing to the residents which behaviors are considered unacceptable and which consequences will be applied in modifying the unacceptable behavior. All the behaviors considered unacceptable that would result in disciplinary measures/consequences, such as “service hours,” and the description of a “service hour” and other consequences that would be applied were not indicated in writing to the resident in the Resident Handbook: Behavior and Corrective Action LASH 330 policy. Additionally, the license holder’s Facility Rules and Due Process System and Consequence policies did not align with the current disciplinary/consequence policies and practices that were described through investigative interviews and outlined in the Resident Handbook and the Standard Operating Procedures for MNTC Staff. Request for Reconsideration. The program submitted information and documentation to support the belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder indicated that all residents are provided with copies and oriented to appropriate facility policy. Additionally, the license holder indicated policies are clearly stated and consistent.
Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0080, subpart 4, items A and B, the license holder must communicate verbally and in writing to a resident who is capable of understanding the facility’s rules and the details of the due process system used in the facility. The rules must address which behaviors are considered acceptable and unacceptable and the reasons why and the consequences that will be applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior. Minnesota Statues, section 245A.04, subdivision 14, paragraph (b), provides that a license holder shall monitor implementation of policies and procedures by program staff. The license holder indicated in the request for reconsideration that the facility’s Lakeside Academy Policy and Procedure Manual specifically explains unacceptable behaviors and provides detail regarding the consequences of unacceptable behaviors. However, during the investigation, the license holder indicated that residents receive the Resident Handbook, which is contained in the Lakeside Academy Policy and Procedure Manual as a separate section. The license holder verified that the Resident Handbook was the only written documentation or manual provided to residents, and the license holder did not indicate that they provided residents with a copy of the Lakeside Academy Policy and Procedure Manual. The Resident Handbook does not clearly describe the facility’s discipline practices or all of the behaviors that would result in consequences. Additionally, while another policy entitled Predictable Responses provide more detailed information about behaviors that result in consequences, that policy was in a manual reported to be a guide for staff. The Predicable Responses policy was not provided to residents, and the policy did not align with the information in the Resident Handbook. As a result, it is appropriate to affirm the citation. There is therefore sufficient evidence to support the violation, and it is affirmed. Additionally, the citation is amended to include Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b) as additional authority for the violation.
Citation 3: The correction order stated that the license holder did not meet requirements for spirituality services and counseling. The license holder considered the residents’ lack of attendance at religious services as a basis for privileges in the facility. According to the Resident Handbook (LASH 330 & 840) and resident (R2 through R4) and staff (SP2 and SP3) investigative interview, religious services are considered a type of scheduled programming and skipping or refusing programming leads to a consequence of “service hours” and loss of privileges. Request for Reconsideration. The program submitted information and documentation to support your belief that the program was in compliance with the applicable law at the time the citation was issued. Specifically, the license holder indicates that while the program involves spiritual services, parents are required to execute a consent form on behalf of residents, and a variance was approved acknowledging that faith-based programming is an integral part of the program. The license holder denies that any alleged punishment was based on a resident refusing to attend a spiritual service and indicates that “service hours” are assigned for residents failing to attend any scheduled programming.
Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0080, subpart 8, item A, residents must be given an opportunity to participate in spirituality services, activities, and counseling on a voluntary basis. A resident must not be required to attend the services or activities. All spirituality services and activities must be held in a location that the residents who do not wish to participate are not exposed to the services or activities. Attendance or lack of attendance at religious services or activities must not be considered as a basis for any right or privilege in the facility. Pursuant to Minnesota Rules, part 2960.0050, subpart 1, item O, a resident has basic rights, including, but not limited to, if applicable, the rights stated in Minnesota Statutes, sections 144.651 and 253B.03. The license holder must ensure the rights in items A to R are protected. Although a variance was approved to allow the program to “require the residents to participate in spirituality services” as part of the faith-based programming, it does not indicate that the license holder is permitted to consider the lack of attendance as a basis for privileges in the facility. Additionally, receiving consequences due to not attending spirituality programming is a violation of a resident’s right to refuse care according to the Healthcare Bill of Rights under Minnesota Statutes, section 144.651, subdivision 12. As a result, it is appropriate to affirm the citation. There is therefore sufficient evidence to support the violation, and it is affirmed. Additionally, the citation is amended to add Minnesota Rules, part 2960.0050, subpart 1, item O, as additional authority for the citation. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the following citations, and they are affirmed: citation 1 as to violations a and b; citation 2; and citation 3. The Commissioner finds it is appropriate to rescind citation 1 as to violation c. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General cc: Jennifer A. Forbes, Attorney
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