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June 20, 2023 Daniel Pfarr, Authorized Agent 180 Degrees Rochester 236 Clifton Avenue Minneapolis, MN 55403-3466 License Numbers: 1106748 (CRF) Dear Daniel Pfarr: On April 17, 2023, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of citations in the Correction Order (Attachment A) issued to you by the Department of Human Services on April 4, 2023. You requested reconsideration of citations 10 and 16. You did not request reconsideration of the remaining citations, and, as a result, those citations are final and not subject to review.
Citation 10: The correction order stated that one of two files reviewed for requirements governing program services did not meet requirements (resident file numbered 3). The emergency plan was not reviewed with the resident at least once every six months. Request for Reconsideration. Your 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, you indicate in the request for reconsideration that the program’s emergency plan is reviewed monthly, with all residents in shelter, on a day chosen at random. During the review, the program provides a mock emergency drill, and a debrief occurs with each resident during which the emergency plan is reviewed. Resident file numbered 3 was a client in the program from January 2022 through August 2022, and the resident reviewed the emergency plan during each month from January through August 2022. You provide emergency procedures reporting forms from February through August 2022.
Reconsideration Determination. Pursuant to Minnesota Rules, part 2960.0080, subpart 14, the license holder must develop a written emergency plan that specifies actions by staff and residents required for the protection of all persons in the case of an emergency, such as a fire, natural disaster, serious illness, severe weather, disappearance of a resident, or other situation that may require a law enforcement response or other emergency response. The plan must be developed with the advice of the local fire and emergency response authorities. The plan must specify responsibilities assumed by the license holder for assisting a new resident who requires emergency care or special assistance to a resident in emergencies. The license holder must review the plan with staff and residents at least once every six months. The license holder must keep documentation showing compliance with the emergency plan and the semiannual review. During the licensing review, the licensor requested information from the program and provided 24 hours after the onsite review was conducted to provide any further documents. The program did not provide documentation at the time of the licensing review or within the 24-hour period that demonstrated compliance. There is therefore sufficient evidence to support the violation, and it is affirmed. Citation 16: The correction order stated that one file reviewed for requirements governing shelter discharge documentation did not meet requirements (resident file numbered 3). A transition services plan was not completed. Request for Reconsideration. Your 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, you indicate in the request for reconsideration that a transition plan for resident file numbered 3 was completed, but you acknowledge that not all necessary information had been included. You indicate the program now provides additional details, that the transition services plan has been integrated into a database, that the program is working to update language in the transition services plan, and that staff have been retrained staff on how to accurately complete a transition services plan. You provide a copy of the resident’s transition plan dated December 22, 2021, a screenshot of a blank transition services plan from the program’s database, and training certificates.
Reconsideration Determination. Pursuant to Minnesota Rules, parts 2960.0520, subpart 2, item C, if a resident remains in shelter for more than ten days, the license holder must follow the discharge requirements of part 2960.0190, subparts 1, item A; and 2, and must note the name and address of the party the resident was released to following discharge. Pursuant to Minnesota Rules, parts 2960.0190, subpart 1, items A, prior to the resident’s release from the program, the license holder, in conjunction with the placing agency, must develop a transition services plan for the resident. The plan must recommend ways to meet the resident’s needs and identify resources that are available in the community to address the resident’s continuing needs after release from the facility. The plan must consider the environment into which the resident will return and recommend how the resident may deal with issues and potential challenges within that environment. The plan must be developed with input from the resident, the resident’s family members, if appropriate, the providing school district, and the person who will provide support services to the resident upon release. A copy of the plan must be given to the resident and to the school, or to the residential treatment facility that the resident will attend or is placed in after the release. Pursuant to item B, the transition plan must include at least the elements in subitems (1) to (7): (1) housing, recreation, and leisure arrangements; (2) appropriate educational, vocational rehabilitation, or training services; (3) a budget plan and a description of the resident’s financial and employment status; (4) transportation needs; (5) treatment services; (6) health services; and (7) personal safety needs. Although you have now taken steps to improve the transition services plan, you acknowledge in your reconsideration request that the transition services plan for resident file number 3 did not contain all required information. There is therefore sufficient evidence to support the violation because the transition services plan did not document all the information required by Minnesota Rules, part 2960.0190, subpart 1, item A. The violation is affirmed and revised to include item B 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 citations 10 and 16, and they are affirmed with the revision that Minnesota Rules, part 2960.0190, subpart 1, item B is added as additional authority for citation 16. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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