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March 13, 2023 Marshall Smith, Authorized Agent Commissioner of Department of Human Services 444 Lafayette Road North Saint Paul, MN 55164 License Numbers: 801558 1083681 Investigation Numbers: 202204103 202207619 202208404 CORRECTION ORDER Dear Marshall Smith, On November 1 through 4, 2022 a licensing review and investigation of Minnesota Security Hospital dba Forensic Mental Health Program, located at 100 Freeman Drive, Saint Peter, MN 56082, and the Forensic Mental Health Program, located at 1703 County Road 15, Saint Peter, MN 56082, was conducted to determine compliance with state and federal laws and rules governing the provision of secure mental health treatment services under the MSH Variance to Minnesota Rules, parts 9520.0500 to 9520.0690 (Rule 36) and the Positive Supports Rule under Minnesota Rules, parts 9544.0050 through 9544.0140. 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. Practices 1. Citation: Minnesota Variance, part MSH.0011, subpart 3. Violation: Two of thirty grievances reviewed did not meet requirements. The grievances responded to on April 14, 2022, and April 26, 2022 did not include the date it was filed, therefore, it was not able to be determined if the grievance was responded to within ten days. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the grievance practice meets all applicable requirements. Personnel Files 2. Citation: Minnesota Statues, section 245A.04, subdivisions 1, paragraph (c) and 14, paragraph (b); Minnesota Variance, part MSH.0015, subparts 1, item A; and 2, items A and C; and Minnesota Rules, part 9544.0090, subpart 1. Violation: Six of six personnel files reviewed for requirements governing orientation did not meet requirements in the following ways: a. The staff person was not orientated to the following required topics before providing direct individual care: 1. Job duties, including documentation (personnel files numbered 1, 3, 13, 20 and 21); 2. Recovery concepts and principles, including the perspectives of individuals served (personnel files numbered 20 and 21); 3. Patient rights (personnel file numbered 1); 4. Suicide assessment and risk management (personnel file numbered 1); 5. Training identified by the license holder’s training plan as meeting the requirements of Minnesota Rules, chapter 9544 (personnel files numbered 3, 13, 20, and 21); and 6. Emergency procedures appropriate to the position (personnel files numbered 20 and 21) b. Orientation to the following was not completed within the first 30 days of employment: 1. Facility policies and procedures, including the programs drug and alcohol policy (personnel files numbered 20 and 21); 2. Treatment needs of individuals, including psychiatric disorders and co-occurring disorders (personnel files numbered 13, 20, and 21); and 3. Treatment models and best practices that are currently used in the primary service unit (personnel files numbered 3, 12, 13, 20, and 21). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements, including for any staff person providing temporary coverage. Within 30 days of receipt of this order, submit documentation personnel files numbered 1, 3, 12, and 13 have been trained on all required orientation topics. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated September 9, 2019. 3. Citation: Minnesota Statues, section 245A.65, subdivision 3; Minnesota Variance, part MSH.0015, subpart 2, item D; and Minnesota Rules, part 9544.0090, subpart 3. Violation: Fourteen of sixteen personnel files reviewed for requirements governing annual training did not meet requirements. The file did not contain documentation the following training was completed annually: a. Vulnerable adult calendar year 2021 (personnel files numbered 2 and 9); b. Maltreatment of minors calendar year 2022 (personnel file numbered 9); c. Program abuse prevention plan calendar year 2022 (personnel file number 9); d. Patient rights calendar year 2022 (personnel files numbered 2 and 9); e. Suicide assessment and risk management calendar year 2022 (personnel files numbered 2 and 9); f. Emergency procedures appropriate for the position calendar years 2021 (personnel file numbered 14) and 2022 (personnel files numbered 2 and 9); g. Person-centered thinking principles calendar years 2020 (personnel files numbered 3, and 17 through 19); 2021 (personnel files numbered 2, 3, and 17 through 19); and 2022 (personnel files numbered 3, and 17 through 19); h. Training identified by the license holder’s training plan as meeting the annual requirements of Minnesota Rules, chapter 9544 in calendar years 2020 (personnel files numbered 2, 3, 6 through 8, 10, and 14 through 19); 2021 (personnel files numbered 2, 4, 6 through 10, and 14 through 19); and 2022 (personnel files numbered 2, 3, 4, 6 through 10, and 14 through 19; and i. The staff completed at least twenty-four hours of annual training (personnel files numbered 2 and 16). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and completion of annual training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates all staff persons identified above received the required annual training for 2022. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated September 9, 2019. 4. Citation: Minnesota Variance, part MSH.0014, subpart 2. Violation: Three of sixteen files reviewed for requirements governing an annual job evaluation did not meet requirements. The file did not contain documentation to demonstrate an annual evaluation was completed in calendar year 2020 (personnel file numbered 2) and 2021 (personnel files numbered 4 and 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure annual job evaluations meet all applicable requirements. Individual Files Individual files are identified in the follow manner: · North Campus (license number 1083681): Individual files numbered 9, 13, 17, and 18 · Main Campus (license number 801558): Individual files numbered 1 through 8, 10 through 12, 14 through 16, and 19 5. Citation: Minnesota Variance, part MSH.0004, subpart 5, item A.
Violation: One of five individual files reviewed for requirements governing specialized assessments (individual file numbered 16) did not meet requirements. An educational assessment was not completed within 30 days of receiving a referral. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure specialized assessments meet all applicable requirements. 6. Citation: Minnesota Variance, part MSH.0004, subpart 8, item B. Violation: Two of nine individual files reviewed for requirements governing treatment planning did not meet requirements in the following ways: a. The individual’s treatment plan was not updated after a substance use disorder assessment was completed (individual file numbered 15); and b. The individual treatment plan (ITP) did not include the following: 1. Identification of the staff who were responsible to deliver the interventions on the ITP dated June 27, 2022 and July 27, 2022 (individual file numbered 15); and 2. The individual’s signature to acknowledge participation in the development or revision of the ITP dated August 23, 2021, October 11, 2021, and June 6, 2022 (individual file numbered 16). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure treatment planning meets all applicable requirements. Repeat Citation: The license holder was cited for a similar violation in a correction order dated September 9, 2019. 7. Citation: Minnesota Variance, part MSH.0008, subpart 3, item 1. Violation: One of five files reviewed for requirements governing standards for the use of restraint and seclusion (individual file numbered 4) did not meet requirements. The file did not contain an individual support plan. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure standards for the use of restraint and seclusion meet all applicable 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 Ginny Benson: 1. By secure email to: ginny.benson@state.mn.us ; or 2. By mail to: Commissioner, Department of Human Services ATTN: Ginny Benson 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 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
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