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December 8, 2023 CERTIFIED MAIL Kendahl Sweet, Authorized Agent Pinehaven Youth and Family Services PO Box 667 Brainerd, MN 56401 License Number: 1046389 Child Placing Agency (Rule 4) Complaint Report Number: 202307564, 202301570 ORDER OF CONDITIONAL LICENSE Dear Mr. Sweet: The Department of Human Services (DHS) is placing your license to provide child placing agency services at Pinehaven Youth and Family Services, located at 13417 Cypress Drive, Baxter, MN, and your authorization to perform licensing functions on conditional status for two years, beginning December 8, 2023. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with child foster care licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On November 7, 2022, DHS licensors conducted an unannounced licensing visit at your agency located at 13417 Cypress Drive, Baxter, MN. As a result of this licensing visit, the DHS licensors determined that your program failed to comply with the laws and rules that apply to a licensed child-placing agency, citing four violations. In addition, DHS completed a licensing investigation in February and July 2023 and identified several additional violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of children served by the program. · Nature: Violations cited below reflect serious concerns for the health and safety of children in foster homes licensed by Pinehaven Youth and Family Services. Pinehaven failed to maintain logs and keep confidential information stored in a secure location. Pinehaven failed to complete child foster care applications, respond to DHS correction orders, and investigate licensing violations in a timely manner. DHS completed a licensing investigation and identified several additional violations. · Chronicity: Your program was licensed on May 1, 2007. Since that time, your program has demonstrated a history of non-compliance with licensing rules and statutes. The information below summarizes this history: o July 29, 2008, Correction Order: Five violations. o July 30, 2010, Correction Order: Ten violations. o June 19, 2012, Correction Order: Three violations. o September 29, 2014, Correction Order: Ten violations. o April 27, 2016, Correction Order: Thirteen violations. o May 25, 2016, Order to Pay a Fine Background Study Fine: One violation. o August 28, 2018, Correction Order: Five violations. o December 31, 2018, Order to Pay a Fine Background Study Fine: One violation. o August 26, 2019, Order to Pay a Fine Background Study Fine: One violation. o December 11, 2019, Correction Order: One violation. o August 28, 2020, Correction Order: Six violations. o August 5, 2022, Correction Order: Seven violations, three were repeat violations. · Severity: Many of the violations that led to the Conditional license relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of children in your care, your license to provide child placing agency services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. Failing to maintain Licensing Logs 1. Violation: On November 7, 2022, during an unannounced visit, DHS determined that Pinehaven did not have an application tracking log. Rule Violated: Minnesota Rules, part 9543.0040, subpart 8. Repeat Violation: In a Correction Order that DHS issued on August 5, 2022, you were previously found in violation of this same rule. Corrective Action Required: Pinehaven must track the progress of each application for licensure on an application tracking log which will include detailed information regarding the status of each pending license application. 2. Violation: On November 7, 2022, during an unannounced visit, DHS determined that Pinehaven did not have a complaint tracking log. Rule Violated: Minnesota Rules, part 9543.0070, subpart 5, paragraph A. Repeat Violation: In a Correction Order that DHS issued on August 5, 2022, you were previously found in violation of this same rule. Corrective Action Required: Pinehaven must submit a completed complaint tracking log with detailed information regarding the status of each licensing complaint investigation. Confidentiality and Safekeeping of Records 3. Violation: On November 7, 2022, during an unannounced visit, DHS determined that Pinehaven did not allocate office space in such a way as to ensure confidentiality and the safekeeping of records. You had twenty child foster care applications that did not have a file folder and were in a pile of papers on top of a desk. Rule Violated: Minnesota Rules, part 9545.0785, subpart 2. Corrective Action Required: Pinehaven must ensure that office space is allocated to ensure confidentiality and the safekeeping of records. Failure to complete the child foster care license application process 4. Violation: On November 7, 2022, during an unannounced visit, DHS determined that Pinehaven failed to process three child foster care applications promptly as required: · Pinehaven received an application (APP1) on October 8, 2022, but had not yet submitted a preliminary information form (PIF) as of November 7th. · Pinehaven received an application (APP2) and individual fact sheets. There is documentation that you contacted the applicant in June 2022 and an incomplete application letter was sent on October 5, 2022. As of November 7, 2022, a PIF was not submitted. · Pinehaven received an application (APP3) and individual fact sheets. There is documentation that you contacted this applicant in September, October, and November. An incomplete application letter was sent on October 5, 2022. As of November 7, 2022, a PIF had not been submitted. Statute Violated: Minnesota Statutes, section 245A.035, subdivision 5; Minnesota Statutes, section 245A.16, subdivision 1; and, Minnesota Rules, parts 9543.0040, subparts 2, 4, 5, and 8; and 9543.0060, subpart 4 and 5. Corrective Action Required: Pinehaven must submit a preliminary information form (PIF) for every application received to DHS within 10 days of receipt. Failure to timely respond to the Correction order and to correct the licensing violations 5. Violation: You failed to respond promptly to the correction order dated August 5, 2022 (mailed on October 6, 2022). On December 2, 2022, you emailed your correction order response and on December 16, 2022, you sent documentation of the corrections. Several of the documents, including the application tracking log, grievance policy, and your statement of compliance with ICWA, failed to meet the requirements, as described below. Statue violated: Minnesota Statutes, section 245A.06, subdivision 1. Corrective Action Required: In the future, Pinehaven must respond to any and all correction orders within 30 days as required. 6. Violation: The Department of Human Services (DHS), Division of Licensing received your response to the August 5, 2022, correction order in December 2022. The information you submitted in response to the grievance policy violation was insufficient. The Pinehaven grievance policy for care providers identifies the executive director as the highest level of authority in the agency and that the executive director will bring any grievance to the board if necessary. Statute violated: Minnesota Statutes, section 245A.04, subdivision 1(d). Corrective Action Required: Pinehaven will revise its grievance policy to identify that grievances can be brought directly to the highest level of authority in its program; for non-profits, this is the board of directors. 7. Violation: The Department of Human Services (DHS), Division of Licensing received your response to the August 5, 2022, correction order in December 2022. The information you submitted in response to the Description of Agency Program and Services was insufficient. The agency failed to include a statement that it complies with (1) the Indian Child Welfare Act, Public Law 95-608; (2) the Minnesota Indian family preservation act, Minnesota Statutes, sections 260.751 to 260.835; (3) the heritage act, Minnesota Statutes, sections 259.29, 260C.193, subdivision 3, and 260C.212 to 260C.215; and (4) the interstate compact on the placement of children, Minnesota Statutes, section 260.851. Rule violation: Minnesota Rules, part 9545.0815, subpart G. Corrective Action Required: Pinehaven must submit a statement that complies with Minnesota Rules, part 9545.0815, subpart G. 8. Violation: The Department of Human Services (DHS), Division of Licensing received your response to the August 5, 2022, correction order in December 2022. The information you submitted in response to the complaint log was insufficient. DHS is aware that at least one complaint was reported in 2022 and should have been listed on the complaint log. Rule Violation: Minnesota Rules, part 9543.0070, subpart 5, paragraphs A and B. Corrective Action Required: Pinehaven will submit a completed complaint log to DHS. Failure to Timely Investigate License Complaints 9. Violation: On May 27, 2022, Pinehaven was notified that Wadena County had screened in a child protection assessment for one of your child foster care homes (FH1). On November 7, 2022, during an unannounced visit, you were unable to provide any licensing complaint investigation documentation for this complaint. Rule violated: Minnesota Rules, part 9543.0070, subpart 5, paragraphs A and B. Corrective Action Required: Pinehaven maintain a register for recording complaints about licensed programs and tracking the status of each investigation and record in the license holder's file the disposition of each complaint involving the license. Licensing Investigation Findings Complaint Report Number: 202307564 DHS received a complaint alleging concerns about the placement of foster children in a foster home (FH2) licensed by Pinehaven. The following violations 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. Violation: Pinehaven failed to ensure that FH2 was able to consistently meet the requirement for a 1:5 ratio when they approved the placement of seven foster children in the home. Citation: Minnesota Rules, part 2960.3030, subpart 1. Corrective Action Required: Pinehaven must ensure that foster homes can maintain a ratio of one adult for every five children. 2. Violation: Pinehaven failed to ensure compliance with capacity limitations in FH2 when they approved the placement of seven high-needs children with one caregiver. Citation: Minnesota Rules, part 2960.3030, subpart 2, paragraph C, items (1), (4), and (5). Corrective Action Required: Pinehaven must limit the number of foster children that a foster home may accept based on the factors outlined in part 2960.3030, subpart 2, paragraph C, items (1) through (5). 3. Violation: Pinehaven failed to ensure that all items cited on a May 10, 2022, fire marshal inspection were completed before children were placed in the home, and bedrooms used by the children did not have proper egress windows and/or window wells. Citation: Minnesota Rules, part 2960.3050, subpart 2, paragraphs D and E. Corrective Action Required: Pinehaven must develop and implement a policy to ensure that violations cited by the Fire Marshal are corrected as required. 4. Violation: Staff at Pinehaven, SP1, did not cooperate with Wadena County Child Protection in the investigation of the FH2 home when they argued with the county worker during the child protection investigation on several occasions. Citation: Minnesota Rules, part 9543.0070, subpart 1, paragraph B. Corrective Action Required: Pinehaven will ensure that all staff cooperate with county child protection in conducting the licensing investigation required under Rule. Complaint Report Number: 202301570 DHS received a report that alleged that licensing complaints were not investigated and that a confidential reporter’s identity was disclosed to the license holder. DHS determined that your program failed to follow licensing rules and statutes, as described below. Corrective action for each violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. 1. Violation: Pinehaven Youth and Family Services submitted the agency complaint log to DHS on February 24, 2023. DHS determined that Pinehaven was aware of screened-out child protection reports from September 6, 2022, September 21, 2022, and September 29, 2022, which were not recorded on the agency’s licensing complaint log as required. Citation: Minnesota Rules, part 9543.0070, subpart 5, paragraphs A and B. Corrective Action Required: Pinehaven must submit a completed complaint tracking log with detailed information regarding the status of each licensing complaint investigation. 2. Violation: Pinehaven Youth and Family Services failed to affiliate the background study for a staff person (SP1) to the agency’s roster for the Rule 4 license. Citation: Minnesota Statutes, section 245C.07, paragraph (f), clause (1). Corrective Action Required: Pinehaven will ensure background studies for staff are completed and/or affiliated to the agency’s roster for their Rule 4 license. 3. Violation: Pinehaven Youth and Family Services staff (SP1) interviewed FH2 and determined that FH2 yelled and swore at children in the home. FH2 admitted to doing this, and SP1 cautioned FH2 not to do this in the future but failed to issue a correction order for the violation. Citation: Minnesota Rules, part 9543.0090, subpart 2. Corrective Action Required: Pinehaven must issue a correction order for licensing violations that do not imminently endanger the health, safety, or rights of persons served by the program. CONDITIONAL LICENSE TERMS In addition to the child placing agency licensing rules and statutes, you are required to comply with the following terms: 1. You must comply with all applicable laws and rules governing private child placing agencies under Minnesota Rules, parts 9545.0755 to 9545.0845 (DHS Rule 4); Minnesota Rules, parts 9543.0010 to 9543.0150 (DHS Rule 13); Minnesota Rules, parts 2960.3000 to 2960.3340; and Minnesota Statutes, Chapters 245A and 245C, and 260E. 2. Within 30 days from receipt of this order, you must identify a consultant, approved by DHS, who will assist you in developing policies and procedures for performing Pinehaven’s child foster care licensing responsibilities in accordance with all applicable Minnesota statutes and rules. To obtain approval of the consultant from DHS, you must submit a copy of the consultant’s resume, including relevant experience, and a copy of the consultant’s current credentials. 3. Within 60 days from receipt of this order, you must develop updated written policies and procedures and submit them to Pinehaven’s DHS Licensor for review and approval for each of the following: a. placement decisions, including respite placements, in your child foster care homes, that align with laws and rules governing child foster care homes and child-placing agencies; in addition, Pinehaven will develop a placement policy that considers the best interests of all children in the home and will outline a process whereby placement decisions are staffed and approved by the agency’s management prior to placement. b. routine supervisory direction and oversight of each staff member’s casework and coordination of services for each foster child by an LISW or LICSW, as required; the policy must outline the frequency and type of staff supervision the agency provides so that the integrity and quality of the agency’s work is assured. The policy must specifically address the review of agency home studies and home study update reports and set forth expectations for how a home study is to be conducted and the content of home study reports. In addition, Pinehaven must document how you intend to train new staff on completing home study assessments and updates. c. investigation of all incidents, reports, and complaints that represent possible licensing violations. The policy must include expectations for timelines and documentation of investigative activities. In addition, Pinehaven will develop a process to ensure that all concerns affecting the health and safety of foster children are thoroughly addressed. d. determining appropriate agency response to substantiated licensing violations, including the issuance of correction orders and recommending licensing sanctions when appropriate. e. develop a process to ensure that all concerns affecting the health and safety of foster children are thoroughly addressed in the home studies and home study update reports and that such concerns are resolved prior to recommending the issuance or renewal of a license. 4. Pinehaven must review and bring all current child foster care licensing files into compliance with all Minnesota Statutes and Rules within 30 days of receipt of this order. Pinehaven will fully cooperate with a file review completed by DHS to ensure that this has been completed. 5. Within 30 days from receipt of this order, Pinehaven must submit a license application tracking log using the DHS template provided to Pinehaven with detailed information regarding the status of each pending license application including the following: · name(s) of the applicant(s). · the name(s) and placement date of child(ren) in care with the applicant(s). · if applicable, the date the signed application was received by the agency. · the date the Preliminary Information Form (PIF) was submitted to DHS. · the date background studies were initiated; a detailed status update of the pending application, including any barriers to completing the license application. · the date the license application is completed; and · the date a recommendation was submitted to the Commissioner to issue a license, deny the application, or the date the application was withdrawn if requested by the applicant. Pinehaven must submit its recommendation to DHS within 20 working days of completing each license application. 6. While Pinehaven’ s authorization to perform licensing functions is on conditional status, Pinehaven must submit each newly completed initial license application file to DHS for review before recommending initial licensure. If DHS determines that all required actions were not completed for a new license application, Pinehaven shall review the file and application process and shall take appropriate corrective action. 7. Pinehaven must conduct timely investigations of allegations of violations of rules or statutes governing licensure of child foster care programs pursuant to Minnesota Statutes, section 245A.16, subdivision 2. · Each licensing complaint Pinehaven receives about a child foster home must be immediately documented on the agency complaint tracking log. · Any report Pinehaven receives that alleges potential maltreatment of a foster child must immediately be reported to the local child protection agency in the county where the foster home is located. · For reports that do not allege potential maltreatment of a child, Pinehaven must initiate the licensing investigation within three working days of receiving the complaint. · Each licensing investigation shall be completed within 45 days of receipt. If extenuating circumstances exist that would prohibit Pinehaven from completing a licensing investigation within 45 days, you must contact your DHS licensor for technical assistance. · Each licensing investigation must be documented on a Licensing Intake Complaint Form. · The Licensing Intake Complaint form must be sent to your DHS Licensor for review. 8. Pinehaven must submit timely licensing action recommendations to the Commissioner, pursuant to Minnesota Statutes, section 245A.16, subdivision 2 and Minnesota Rules, part 9543, subpart 5. · If the investigation conducted provides evidence that the commissioner should suspend, revoke, or make conditional a license due to serious or chronic licensing violations at the child foster care program, Pinehaven shall make that recommendation to the commissioner within ten working days of the completion of the investigation. · If upon completion of the license application process, there is evidence that the commissioner should deny an application, Pinehaven shall make the recommendation to the commissioner within 20 working days of the completed application. · The licensing action must be sent to your DHS Licensor for review prior to submission. 9. All child foster care licensing staff, including staff with supervisory oversight of child foster care licensing staff, will participate in all DHS trainings including but not limited to: Licensing 101, CFC Basics Plus, CFC Home Safety checklist, and Licensing Complaint Investigations. Within six months from receipt of this order, all Pinehaven staff will register/attend all DHS Licensing. Thereafter, all newly hired licensing staff, including staff with supervisor oversight will be required to complete all DHS trainings within the first six months of their employment. Pinehaven is responsible for maintaining documentation of training completed for each staff person. 10. Pinehaven must schedule monthly calls/meetings with their DHS Licensor and licensor’s supervisor to discuss any current case concerns and to seek technical assistance where needed. In addition, the calls/meetings will include a discussion of any new licensing complaints and technical assistance needed by Pinehaven. It will be the responsibility of Pinehaven to bring any cases needing consultation to this meeting. 11. Pinehaven staff will immediately consult with DHS Licensing triage on any case where there is a concern for imminent risk of harm to children in placement. Pinehaven will consult with DHS Licensing on all open and screened-out child protection investigation reports upon receiving notice of the report. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · be in writing. · clearly state that you are requesting reconsideration of the conditional license. · list each citation you are challenging and identify what is inaccurate or incomplete about the information in the order. · supply information that is accurate or more complete. · state why you believe your license should not be on a conditional status. · be made before the deadlines provided below. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all child placing agency (Rule 4) and licensing agency authorization (Rule 13) laws and rules.
Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Child placing agencies are required to follow Minnesota Rules, parts 9543.0010 through 9543.0150 (Rule 13) and Minnesota Rules, parts 9545.0755 through 9545.0845 (Rule 4); and Minnesota Rules, parts 9543.0010 to 9543.0150 (Rule 13). · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Tamara Moore, Supervisor, at 651-431-3293. Sincerely,
Mary Kelsey, Unit Manager Licensing Division Office of Inspector General cc: Kara Griffin, Pinehaven Board of Directors Kimberly Henderson, Pinehaven Board of Directors Krista Finnerty Jones, Pinehaven Board of Directors
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