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January 31, 2023 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 AMENDED CORRECTION ORDER Dear Eric Vagle: On March 15, 2022, a licensing investigation of Lakeside Academy, located at 100 Garrison Avenue NE, Buffalo, MN 55313, was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities 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 investigation, a Correction Order was issued on June 10, 2022. The Department of Human Services (“DHS”), Division of Licensing received your request for reconsideration for citations 1 through 3 of that Correction Order on June 10, 2022. On October 12, 2022, DHS issued a Reconsideration Response Correction Order. This Amended Correction Order reflects the final agency decision. Citation 1 as to violation (c) was rescinded from the Correction Order issued on June 10, 2022. This Amended Correction Order supersedes the Correction Order issued on June 10, 2022, which must be destroyed. 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 investigation. 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 Rules, parts 2960.0050, subpart 1, item 0, and 2960.0020, subpart 31.
Violation: 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 that are 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 individual 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, 2021, 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. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all resident’s rights are protected and any discipline implemented meets all applicable requirements. 2. Citation: Minnesota Rules, part 2960.0080, subpart 4, items A and B. Violation: 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 of 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 that are outlined in the Resident Handbook and the Standard Operating Procedures for MnTC Staff. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the facility’s rules and due process system for residents meets all requirements. Within 30 days of receipt of this order, submit to DHS for approval: · Revised policies and resident handbook that outlines which behaviors are acceptable and unacceptable, and what consequences will be applied. The consequences that will be applied need to be reasonable consequences. Within 30 days of DHS approval, submit documentation demonstrating the following: · All staff have been trained on all policies and procedures pertaining to discipline; and · All youth have been provided verbal and written communication on which behaviors are acceptable and unacceptable, and what consequences will be applied. 3. Citation: Minnesota Rules, parts 2960.0080, subpart 8, item A Violation: 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 interviews, 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. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of spirituality services meets all applicable requirements. Within 15 days receipt of this order, the license holder must contact DHS licensing to schedule a meeting to discuss and review the variance pertaining to required religious services. 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: Commissioner, Department of Human Services ATTN: Tina Christensen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Final Agency Decision As stated above, this Amended Correction Order reflects the final agency decision in your request for reconsideration of the Correction Order dated June 10, 2022. As such, the decision is not subject to appeal. 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
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