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May 6, 2024 Su-Fei Wong, Authorized Agent Avanti Center for Girls 7625 Metro Blvd Ste 200 Minneapolis, MN 55439-3057 License Number: 1049979 (CRF) CORRECTION ORDER Dear Su-Fei: On March 4 through 7, 2024, Department of Human Services (DHS) conducted a licensing review at your facility located at 10300 Flanders Street NE, Blaine, Minnesota, 55449 to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, restrictive techniques standards under Minnesota Rules, part 2960.0710 and residential program certification for compliance with the Family First Prevention Services Act, Minnesota Statute, section 245A.25. As a result of this licensing review, a Correction Order is being issued. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. PRACTICES 1. Violation: The license holder did not have a copy of the program abuse prevention plan posted on either living unit. The license holder displayed a summary of the program abuse prevention plan but did not post a plan that contained the full policy. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Correction Action Required: Immediately and on an ongoing basis, the license holder must ensure that the program abuse prevention plan meets all applicable requirements. This violation was corrected during the licensing review. No further corrective action is required. 2. Violation: A controlling individual of the program did not annually review and the sign the plan for the transfer of clients and records upon closure for calendar year 2022. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a). Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a controlling individual annually reviews the plan for transfer of clients and records upon closure. 3. Violation: The license holder did not have documentation to demonstrate that clinical supervision was provided weekly by a licensed mental health professional for three of three weeks sampled: a. February 5 through February 11, 2023; b. September 10 through September 16, 2023; and c. February 11 through February 17, 2024. Rule Violated: Minnesota Rules, part 2960.0630, subpart 2, item B. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of clinical supervision meets all applicable requirements. 4. Violation: The license holder did not provide a written response within five days of the resident filing a grievance on the following dates: a. October 10, 2022; b. March 14, 2023; c. March 20, 2023; d. April 10, 2023; e. April 16, 2023; f. July 9, 2023; g. July 11, 2023; and h. November 29, 2023. Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must provide written responses to grievances within five days and meet all applicable requirements. 5. Violation: The license holder’s satisfaction surveys provided to former residents and their parents did not contain all required elements, including recreation, sleeping accommodations and the accuracy, usefulness, and appropriateness of the screening and assessment of the resident’s physical and emotional well-being and functioning. Rule Violated: Minnesota Rules, part 2960.0140, subpart 1, item A. Corrective Action Required: Immediately and an ongoing basis, the license holder must offer satisfaction surveys that meet all applicable requirements. Within 30 days receipt of the order, submit documentation that demonstrates compliance. 6. Violation: The license holder did not have a process to assess and document a determination of any medical or psychological condition that restraints are contraindicated for and the type of restraints that will not be used on the person based on that determination, prior to using a physical restraint. Statute Violated: Minnesota Statutes, section 245A.211, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that physical restraints meet all applicable requirements. Within 30 days of receipt of this order, submit documentation that demonstrates compliance. 7. Violation: The license holder did not provide vocational skills development services to residents. Rule Violated: Minnesota Rules, part 2960.0590, item G. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program services meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating compliance. PERSONNEL FILES 8. Violation: One of four personnel files reviewed for requirements governing orientation did not meet requirements (personnel file numbered 5). There was no documentation to demonstrate that the staff person received orientation training in emergency procedures. Correction Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation training meets all applicable requirements. 9. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements in the following ways: Documentation did not demonstrate the staff person was trained on: 1. Vulnerable adults maltreatment reporting requirements and definitions in calendar year 2023 (personnel file numbered 2); 2. The license holder’s program abuse prevention plan (personnel files numbered 2 and 7);All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 2 and 7); 3. The use of physical holding or seclusion at least once every two years (personnel file numbered 2); a. Documentation did not demonstrate that the license holder reviewed the emergency plan with staff at least every six months (personnel files numbered 2 and 7); b. Documentation did not include the name of the entity who provided the training (personnel files numbered 2, 4, and 7); and Rule/Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subpart 14, part 2960.0100, subpart 3, item A and subpart 5 and part 2960.0710, subpart 9. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. RESIDENT FILES 1. Violation: One of three resident files reviewed for requirements governing resident information did not meet requirements (resident file numbered 5). The file did not contain information about the resident’s tribal affiliation. Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that resident information meets all applicable requirements. 2. Violation: Four of four resident files reviewed for requirements governing qualified residential treatment programs certification did not meet requirements in the following ways: a. There was no documentation to demonstrate that the license holder contacted and facilitated outreach to each youth’s siblings, including the contact method and each family member’s contact information (resident files numbered 2 and 3); b. There was no documentation of the contact information for all known biological family members and fictive kin of the youth (resident files numbered 2 and 6); c. The license holder did not document in the youth’s file how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youths’ siblings (resident file numbered 3); and d. The program did not provide family-based aftercare support to each youth for at least six months after the youth’s discharge from the program (resident file numbered 7). Statute Violated: Minnesota Statues, section 245A.25, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that qualified residential treatment programs certifications meets all applicable requirements. Within 30 days receipt of this order, submit documentation for two resident files that demonstrates compliance. 3. Violation: One of three resident files reviewed for requirements governing admission criteria did not meet requirements (resident file numbered 1). The file did not contain documentation to demonstrate that the program had assessed whether the program is able to meet the resident’s cultural, emotional, educational, mental health and physical needs. Rule Violated: Minnesota Rules, part 2960.0160, subpart 2, items A and C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission criteria meets all applicable requirements. 4. Violation: Three of three resident files reviewed for requirements governing admission procedures did not meet requirements in the following ways: a. The file did not contain documentation that the license holder completed an inventory of the resident’s personal property, including clothing, upon admission (resident files numbered 1 and 2); and; b. The file did not contain documentation that the license holder communicated facility rules and due process systems to the resident (resident files numbered 1, 2 and 5). Rule Violated: Minnesota Rules, part 2960.0070, subpart 4 and 2960.0080, subpart 4 Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. 5. Violation: One resident file reviewed for requirements governing vulnerable adult orientation and the individual abuse prevention plan did not meet requirements in the following ways (resident file numbered 3): a. There was no documentation to demonstrate that the resident was oriented to the program abuse prevention plan, policies and procedures governing maltreatment of a vulnerable adult and the internal and external reporting policies including the telephone number for MAARC. b. The license holder did not develop an individual abuse prevention plan as required when the resident turned 18 years old. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, 2, and 14. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. 6. Violation: Three of three resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. The health screening was not completed within 24 hours of admission and did not note the resident’s history of abuse, vulnerability to abuse and potential for self injury (resident files numbered 1, 2, and 5); b. The cultural screening was completed but did not contain all required screening questions (resident files numbered 1, 2, and 5); and c. There was no documentation to demonstrate that the license holder completed the screening to determine the resident’s gender based needs (resident file numbered 2). Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, items B and C. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission screenings meets all applicable requirements. 7. Violation: One resident file reviewed for requirements governing program services did not meet requirements (resident file numbered 1). The license holder did not provide education about chemical health to a resident who has had a problem related to inappropriate chemical use, but who does not have a sufficient chemical use history to refer to treatment. Rule Violated: Minnesota Rules, part 2960.0080, subpart 9, item D. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program services meets all applicable requirements. 8. Violation: Three of three resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The individual treatment plan was completed by a staff person who was not under the clinical supervision of a mental health professional (resident files numbered 1, 2, and 5); b. The treatment plan did not identify the treatment strategy (resident files numbered 1 and 2), the individuals responsible for providing treatment (resident files numbered 1, 2, and 5) and a schedule for accomplishing treatment goals and objectives (resident files numbered 1, 2, and 5); and c. The treatment plan did not permit the use of physical holding and seclusion (resident file numbered 2). Rule Violated: Minnesota Rules, part 2960.0600, item A, 2960.0630, subpart 3 item B and 2960.0710, subpart 6. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. 9. Violation: Two of four resident files reviewed for requirements governing service plan reviews did not meet requirements (resident files numbered 1 and 4). The treatment team did not include and document the use of time-out for each resident during the review of the resident’s treatment plan. Rule Violated: Minnesota Rules, part 2960.0080, subpart 5, item D and Minnesota Rules, part 2960.0600, item A, 2960.0630, subpart 3 item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure service plan reviews meets all applicable requirements. 10. Violation: One of four resident files reviewed for requirements governing restrictive procedures did not meet requirements in the following ways (resident file numbered 1): a. On September 3, 2023, the emergency use of physical holding or seclusion did not meet the following conditions: an immediate intervention is necessary to protect the resident or others from physical harm and the physical holding or seclusion used is the least intrusive intervention that will effectively react to the emergency; and b. On September 3, 2023, documentation of the restrictive procedure did not include an explanation of why less restrictive measures failed or were found to be inappropriate. Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items A, B, and K. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure restrictive procedures meets all applicable requirements. 11. Violation: Three of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident files numbered 1 through 3). The file did not contain documentation to demonstrate the license holder returned the residents property to the resident upon discharge. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3 and 2960.0190, subpart 1, item C. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge procedures meets all applicable requirements. 12. Violation: Two of three resident files reviewed for requirements governing transition services plans did not meet requirements. There was no documentation that a copy of the transition services plan was provided to the resident’s school (resident files numbered 1 and 2). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated January 27, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure transition services plans meets 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 DHS Licensing at: 1. By secure email to: madelyn.gilbertson@state.mn.us; or 2. By mail to: Commissioner, Department of Human Services ATTN: Maddy Gilbertson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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 · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 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 20 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 Questions If you have any further questions regarding this matter, you may contact Maddy Gilbertson, Senior Licensor, at 651-431-4585. Sincerely, Maddy Gilbertson, Senior Licensor
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