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February 20, 2024 Suzette Mallum North Homes, Inc 1815 River Road Grand Rapids, MN 55744 License Number: 1056074 (Boys Program) 1028358 (TNT)
CORRECTION ORDER Dear Suzette Mallum, On December 11, 2023, certification reviews of North Homes Boys program, located at 1815 River Road, Grand Rapids, MN, 55744, and North Homes Boys TNT, located at 916 NW 20th Drive, Grand Rapids, MN, 55744 were conducted to determine compliance with state and federal laws and rules governing the provision of The Family First Prevention Services Act under Minnesota Statues 245A.25. As a result of this certification review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.25, subdivision 8, 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 certification review. Corrective action for each violation is required by Minnesota Statutes, section 245A.25 and is hereby ordered by the Commissioner of Human Services. Policies and Practices 1. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraphs (f) and (g). Violation: The license holder’s policies and practices of trauma-informed care did not meet requirements in the following ways: a. The program’s designated spaces available to youth for engaging in sensory and self-soothing activities were not described in policy; b. The program staff did not ensure the designated spaces were available to the youth to use when needed; and c. Policies did not include that the program prohibits the use of aversive consequences for a youth’s violation of program rules or for any other reason. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma-informed care policies and practices meet all applicable requirements. Within 30 days receipt of this order, submit revised policies on trauma-informed care, as identified above, to demonstrate compliance. 2. Citation: Minnesota Statutes, section 245A.25, subdivision 4, paragraphs (b), (f) through (h), and (j). Violation: The license holder’s service delivery plan did not meet requirements. The program’s service delivery plan did not include and describe how the license holder: a. Collaborates with the responsible social services agency and other appropriate parties to implement the youth’s out of home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment; b. Facilitates the participation of a youth’s family members in the youth’s treatment program; c. Contacts and facilitates outreach to each youth’s family members, including the youth’s siblings, and documenting the outreach in the youth’s file, including the contact method and each family member’s contact information; and d. Documents in the youth’s file how the program integrates family members into the treatment process, including after the youth’s discharge, and how the program maintains the youth’s connections to the youth’s siblings. Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s service delivery plan meets all applicable requirements. Within 30 days receipt of this order, submit a service delivery plan that meets requirements to demonstrate compliance. Personnel Files Personnel files reviewed are identified in the following manner: · Personnel files numbered 1 through 5: Boys Program and TNT 3. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h). Violation: Five of five personnel files reviewed for requirements governing training did not meet requirements in the following ways: a. There was no documentation to demonstrate that prior to direct contact with a youth, a staff was oriented to: 1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel files numbered 1 through 3); and 2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 through 5); and b. There was no documentation to demonstrate staff were trained annually to: 1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel file numbered 1); and 2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 and 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure training meets all applicable requirements. Youth Files Youth files reviewed are identified in the following manner: · TNT: Youth files numbered 1 and 2 · Boys Program: Youth files numbered 3 through 5 4. Citation: Minnesota Statues, section 245A.25, subdivision 3, paragraphs (c) through (e). Violation: Five of five youth files reviewed for requirements governing trauma-informed care did not meet requirements. Documentation did not demonstrate: a. Whether the youth participated in reviewing and developing their individual treatment or service plan (youth files 1 and 5); b. Whether the license holder adjusted services for the youth to address any additional needs of the youth (youth files numbered 1 through 3); c. If an assessment was completed to determine if the youth was in need of trauma-specific treatment interventions (youth files numbered 1 through 5); d. How the license holder recognized the impact of trauma on the youth when determining the youth’s service needs and providing services to the youth (youth files numbered 1 through 5); and e. In the youth’s treatment plan, how the program would provide trauma-specific treatment interventions to the youth to target the youth’s specific trauma-related symptoms (youth files numbered 1 through 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of trauma-informed services meet all appliable requirements. 5. Citation: Minnesota Statues, section 245A.25, subdivision 4, paragraphs (b), (c), and (f) through (i). Violation: Five of five youth files reviewed for requirements governing services in qualified residential treatment programs did not meet requirements. Documentation did not demonstrate the license holder: a. Collaborated with the responsible social services agency and other appropriate parties to implement the youth’s out-of-home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment (youth files numbered 1, 2, and 3); b. Completed treatment plan reviews for July 2023 (youth file numbered 2) and February, March, April, and June 2022, and January and March 2023 (youth file numbered 5); c. Facilitated the participation of a youth’s family members in the youth’s treatment program that was consistent with the youth’s best interests and according to the youth’s out-of-home placement plan (youth files numbered 2 through 5); d. Contacted and facilitated outreach to each youth’s family members, including the youth’s siblings, and documented the contact method and contact’s information in the youth’s file (youth files numbered 1 through 5); e. Maintained a record of contact information for all known biological family members and fictive kin of the youth (youth files numbered 1 through 5); f. Integrated family members into the youth’s treatment process, including after the youth’s discharge from the program, and the youth’s connections to their siblings (youth files 1 through 5); g. Provided discharge planning and family-based aftercare support for at least six months after the youth’s discharge from the program (youth files 3 through 5); and h. Ensured monthly contact with the youth and the youth’s caregivers to promote the youth’s engagement in aftercare services and regular evaluation of the family’s needs (youth files 3 through 5). Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure services of a qualified residential treatment program meet all appliable requirements. If you fail to correct the violations specified in the Correction Order within the prescribed timelines the Commissioner may rescind certification pursuant to Minnesota Statutes, section 245A.25, subdivision 9. Submissions required as part of a corrective action ordered must be sent to Tina Christensen 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 Tina Christensen, Human Services Licensor at 651-431-6610, as soon as possible.  Tina Christensen, MH/SUD/CRF Senior Licensor Licensing Division Office of Inspector General
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