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June 16, 2023 Stephen Williams, Authorized Agent Kadiri House LLC PO Box 7227 Denver, CO 80207 License Number: 1095378 (CRF)
CORRECTION ORDER Dear Stephen Williams: On March 13 through 15, 2023, a licensing review of Kadiri House located at 2131 North 6th St. Suite #2, Minneapolis, MN 55411, was 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, and children’s group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220. As a result of this licensing review 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 violations 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. Postings, Policies, and Practices 1. Citation: Minnesota Statutes, sections 245A.65, subdivisions 1, paragraph (d), and 2, paragraph (a). Violation: The license holder failed to ensure postings met requirements. A copy of the program abuse prevention plan (PAPP) and the internal and external reporting policies and procedures for maltreatment were not posted in a prominent location in the facility. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program abuse prevention plan meets all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required. 2. Citation: Minnesota Statutes, section 245A.04, subdivision 14, paragraph (b), and Minnesota Rules, parts 2960.0080, subparts 4, items A through C, and 5, and 2960.0160, subpart 4, item A. Violation: The license holder failed to meet requirements pertaining to facility rules in the following ways: a. Copies of the rules governing conduct and disciplinary consequences provided to the youth did not contain: 1. All of the rules implemented in practice by the license holder; and 2. The procedures for obtaining hygiene items; and b. The facility rules did not include interventions used by the program. Room Restrictions and House Restrictions were identified interventions that were not described in policy. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the facility rules meet requirements. 3. Citation: Minnesota Rules, part 2960.0080, subpart 5. Violation: The license holder utilized a disciplinary procedure/practice that is not permitted in DHS Licensed Children’s Residential Facilities. The disciplinary practice identified as Room Restriction required residents to remain in their room for multiple hours per day in response to an unacceptable behavior and/or safety measure. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure all discipline and safety measures meets all applicable requirements. During the licensing review the license holder was ordered to immediately cease the practice of Room Restriction. Within 30 days receipt of this order, submit documentation demonstrating all staff have been trained on appropriate disciplinary measures used at the program. 4. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A. Violation: The license holder’s annual evaluation report of strengths and weaknesses for calendar year 2022 did not include the following required performance indicators: a. Accidents; b. The use of restrictive procedures; c. Grievances; d. Results from resident and family satisfaction surveys; and e. Critical incidents Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s annual evaluation report meets all applicable requirements. Within 30 days receipt of this order, submit a template that includes the required performance indicators to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 5. Citation: Minnesota Rules, section 2960.0080, subpart 17, item A. Violation: Eight of nineteen incident reports reviewed for requirements governing critical incident reports did not meet requirements. Critical incident reports were not submitted to DHS for the identified incidents: a. A resident absconded and did not return within 24 hours (February 9, 2023, December 15, 2022, and November 3, 2022); b. A staff person physically intervened with a resident, when the program was not certified for restrictive procedures, and emergency responders also intervened for one incident (December 28, 2022, November 12, 2022, October 27, 2022, and March 17, 2022); and c. Emergency Responders intervened at the program (December 11, 2022). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the reporting of critical incidents meets all applicable requirements. Personnel Files 6. Citation: Minnesota Statutes, section 245A.041, subdivision 5. Violation: Three of five personnel files reviewed for requirements governing documentation (personnel files numbered 1, 2, and 5) did not meet requirements. Documentation did not include the first date the staff person began working in a facility or setting. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the documentation of the first date of working in a facility or setting meets all applicable requirements. 7. Citation: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, parts 2960.0100, subpart 3, item A, and 2960.0150, subpart 4, item C. Violation: One of three personnel files reviewed for requirements governing orientation training (personnel file numbered 5) did not meet requirements in the following ways: a. The staff person was not oriented to the following: 1. Gender issues, including the psychosocial development of boys and girls; 2. Sexual orientation issues; 3. Physical, mental, sensory, and health-related disabilities, bias, and discrimination; and 4. Resident admission screens; a. The staff person was not oriented to the following required topics before having unsupervised contact: 1. Emergency procedures; 2. Maltreatment of Minors reporting requirements under Minnesota Statutes, section 260E; 3. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues; and 4. General and special needs, including disability needs of residents and families served; and b. The staff person was not oriented to the following required topics within 72 hours of first providing direct contact services: 1. Vulnerable adult maltreatment reporting requirements and definitions in Minnesota Statutes, sections 626.557 and 626.5572; 2. The program’s abuse prevention plan (PAPP); and 3. The program’s internal policies and procedures related to the prevention and reporting of maltreatment. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff person identified above has been trained to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 8. Citation: Minnesota Rules, part 2960.0080, subpart 11, item D. Violation: Three of three personnel files reviewed for the requirements governing medication assistance training (personnel files numbered 1, 2, and 4) did not meet requirements. There was no documentation to demonstrate the staff person received training on the program’s medication administration policies and procedures. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure medication assistance training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation that the staff persons identified above have been trained. 9. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D. Violation: Four of four personnel files reviewed for the requirements governing the use of time-out training (personnel files numbered 1 through 4) did not meet requirements. The staff person was not trained prior to the use of time-out. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of training meets all applicable requirements. 10. Citation: Minnesota Rules, part, 2960.0100, subpart 5. Violation: Four of five personnel files reviewed for requirements governing the documentation of training (personnel files numbered 1 through 3 and 5) did not meet requirements. The date, number of hours, and the name of the entity/person(s) providing the training was not documented to each topic area. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of training meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 11. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0080, subpart 14, 2960.0100, subparts 3 and 5, and 2960.0150, subpart 4, item D. Violation: Two of two personnel files reviewed for requirements governing ongoing training did not meet requirements. There was no documentation to demonstrate the following training occurred: a. The needs of residents and skills development (personnel file numbered 3); b. Vulnerable adults maltreatment reporting requirements for the year 2022 (personnel files numbered 3 and 4); c. The program abuse prevention plan (PAPP) and all internal policies and procedures related to the prevention and reporting of maltreatment for the year 2022 (personnel files numbered 3 and 4); d. The emergency plan at least once every six months for calendar year 2022 (personnel files numbered 3 and 4); and e. At least one hour of training for each 50 hours worked, for a part time staff person (personnel file numbered 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of ongoing training meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. Resident Files 12. Citation: Minnesota Rules, parts 2960.0070, subpart 4 and 2960.0090, subpart 3. Violation: One of four resident files reviewed for requirements governing the inventory and handling of resident property did not meet requirements (resident file numbered 2). The resident’s property was not inventoried upon admission. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the inventory and handling of resident property meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 13. Citation: Minnesota Rules, parts 2960.0050, subparts 3, item A, and 4; 2960.0080, subpart 4; 2960.0160, subpart 4, item B Violation: One of three resident files reviewed for requirements governing admission procedures (resident file numbered 1) did not meet requirements. The license holder failed to complete the following required procedures with the resident within 24 hours of admission: a. Explain and provide a written copy of the resident’s basic rights; and b. Provide a copy of the description of the applicable programs and activities available to the resident in the facility. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of admission procedures meets all applicable requirements. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 14. Citation: Minnesota Statutes, section 245A.65, subdivisions 1, paragraphs (c) and 2, (a) and (b).
Violation: Two of two resident files reviewed for requirements governing vulnerable adult’s orientation and the individual abuse prevention plan (IAPP) did not meet requirements in the following ways: a. There was no documentation to demonstrate the resident received orientation to the required policies and procedures governing the maltreatment of vulnerable adults for the following (resident files numbered 4 and 5): 1. The internal and external reporting policies, including the telephone number for MAARC; and 2. The program’s abuse prevention plan; and b. An IAPP was not developed (resident file numbered 4); and c. The IAPP did not include specific measures to be taken to minimize the risk of emotional abuse that was indicated (resident file numbered 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of the vulnerable adult orientation and development of an IAPP for adult residents. 15. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A and C. Violation: Three of three resident files reviewed for requirements governing admission screens did not meet requirements in the following ways: a. The health screen did not occur within 24 hours of admission (resident file numbered 1); b. The health screen did not include the address for the clinic identified (resident file numbered 2); and c. A written risk management plan was not developed for a resident whose screening indicated that the resident was likely to have sexually abusive behavior (resident file numbered 2). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of admission screens meets all applicable requirements. Within 30 days receipt of this order, submit a Health Screen template that has been approved by a medical professional to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 16. Citation: Minnesota Statutes, section 245A.65, subdivisions 2, paragraph (b) and Minnesota Rules, part 2960.0180, subpart 2, item B.
Violation: Four of four resident files were reviewed for requirements governing treatment plans and service plan reviews did not meet requirements in the following ways: a. There was no date on the treatment plan to demonstrate the development of the plan began within 10 days of admission (resident files numbered 1 through 3); b. The treatment plan did not include individualized goals and a schedule for accomplishing goals and objectives (resident files numbered 1 and 3); c. The individual abuse prevention plan (IAPP) was not reviewed as a part of the service plan review for July, September, and November 2022 (resident file numbered 5); d. The treatment plan was not reviewed on a monthly basis for July and February 2022 (resident file numbered 1) and October 2022 (resident file numbered 3); and e. Monthly review of treatment plans did not identify if changes were needed or recommended (resident files numbered 1 through 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of treatment plans and service plan reviews meet all applicable requirements. Within 30 days receipt of this order, submit a Treatment Plan and Treatment Plan Review for one resident to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 17. Citation: Minnesota Rules, part 2960.0080, subpart 5, item D. Violation: Three of five resident files reviewed for requirements governing time-out procedures did not meet requirements in the following ways: a. Incident report documentation reviewed indicated a time-out was implemented on November 11, 2022 and February 13, 2023 (resident file numbered 1), December 28, 2022 (resident file numbered 7), and March 17, 2022 and February 13, 2023 (resident file numbered 8), and documentation did not include the following: 1. The factors or circumstances which caused the need for the use of time-out; 2. The resident's response to the time-out; 3. The resident's ability to de-escalate during the time-out procedure; and 4. The resident's ability to maintain acceptable behavior after the time-out. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of time-out meets all applicable requirements. 18. Citation: Minnesota Rules, part 2960.0080, subpart 11, items D and E. Violation: Three of three resident files reviewed for requirements governing health care did not meet requirements in the following ways: a. The medication verification form did not include the symptoms that the medication will alleviate (resident files numbered 1 and 2); b. The medication administration record (MAR) did not include the amount of medication given, whether or not the resident received the medication, and the resident’s refusal to take medication for the following months: 1. July, August, September, and November 2022 and February 2023 (resident file numbered 1); and 2. November 2022 (resident file numbered 2); c. The license holder did not document and follow the prescribing physician’s directions for monitoring medications in the following ways: 1. There were missing entries for blood sugar readings and use of diabetic supplies on the medication administration records (MAR) for September, November, and December 2022 (resident file numbered 3); and 2. MARs were not provided for review for the months of October 2022 (resident file numbered 2) and January and February 2023 (resident files numbered 2 and 3). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health care meets all applicable requirements. Within 30 days receipt of this order, submit a MAR for one resident that meets requirements to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 13, 2020. 19. Citation: Minnesota Rules, parts 2960.0190, subpart 1, item A. Violation: One resident file reviewed for requirements governing transition services plans (resident file numbered 1) did not meet requirements in the following ways: a. The plan was not developed prior to the resident’s release from the program; b. Resources available in the community were not identified for recreation, leisure, treatment services, and health services; c. Recommendations for how the resident may deal with issues and potential challenges within the environment they were returning to were not provided; and d. The plan was not developed with input from the resident and the resident’s family. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of discharge documentation meets all applicable requirements. Within 30 days receipt of this order, submit a revised template for a transition service plan to demonstrate compliance. Repeat Violation: This is a repeat licensing violation. The license holder was cited for similar violations in a Correction Order dated November 21, 2022. 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: 1. By secure email to: tina.christensen@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Tina Christensen 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 me as soon as possible. Tina Christensen, Human Services Senior Licensor Licensing Division Office of Inspector General 651-431-6610
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