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April 24, 2024 John Trunkey, Authorized Agent Aurora Plains Academy 1400 East 10th Street Plankinton, SD 57368 Certificate Number: 1079811 (CRF) CORRECTION ORDER Dear John Trunkey: On April 15 and 16, 2024, a review for an out-of-state certification of Aurora Plains Academy, located at 1400 East 10th Street, Plankinton, SD, was conducted to determine compliance with state and federal laws and rules governing the provision of children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, and residential treatment for severe emotional disturbance under Minnesota Rules, part 2960.0580 through 2960.0700, and restrictive techniques standards under Minnesota Rules, part 2960.0710, (Rule CRF). As a result of this 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 certificate 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 certificate holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review and 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. Physical Plant and Practices 1. Citation: Minnesota Rules, part 2960.0200, item A. Violation: The facility was not kept in good repair. A DHS Licensor observed bathroom and shower stalls in each living unit’s bathroom in need of repair. PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity Employer http://www.dhs.state.mn.us/licensing Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure the facility’s physical plant and environment meet all applicable requirements. 2. Citation: Minnesota Rules, part 2960.0060, subpart 3, item A. Violation: The certificate holder’s program evaluation did not meet requirements. An annual evaluation of the strengths and weaknesses of the program was not completed for calendar years 2022 and 2023. Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure that annual outcome measures and evaluation of the program meets all applicable requirements. 3. Citation: Minnesota Rules, part 2960.0710, subpart 11. Violation: The certificate holder did not review the patterns of the use of restrictive procedures, according to requirements, at least quarterly for the calendar year 2023. Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure that the review of patterns of the use of restrictive procedures meets all applicable requirements. 4. Citation: Minnesota Rules, part 2960.0800, subpart 11, item D. Violation: The certificate holder’s plan for the safe storage and delivery of medicine did not meet requirements in the following ways: a. The plan did not demonstrate how the certificate holder developed the plan in consultation with a medically licensed person; and b. Current procedures used in practice were not identified in the plan. Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure the plan for the safe storage and delivery of medicine meets all applicable requirements. Within 30 days receipt of this order, submit a revised plan for the safe storage and delivery of medicine that demonstrates compliance. 5. Citation: Minnesota Rules, part 2960.0630, subpart 2. Violation: The certificate holder’s documentation of clinical supervision did not meet requirements. Documentation did not demonstrate that a mental health professional provided weekly clinical supervision either face-to-face or through an ancillary meeting to all staff providing program services to a resident for the following sampled weeks: a. March 31, 2024 through April 6, 2024; and b. April 7, 2024 through April 13, 2024. Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure that clinical supervision meets all applicable requirements. Personnel Files 6. Citation: Minnesota Rules, parts 2960.0080, subpart 14; 2960.0100, subparts 3 and 5; 2960.0150, subpart 4, item C, and 5; and 2960.0650, subpart 1, items B, E, F, and G. Violation: Five of five personnel files reviewed for requirements governing orientation and ongoing training did not meet requirements in the following ways: a. Orientation training to the following was not completed: 1. Gender issues, including the psychosocial development of boys and girls (personnel files numbered 3 and 5); 2. Sexual orientation issues (personnel file numbered 5); 3. Physical, mental, sensory, and health-related disabilities, bias, and discrimination (personnel files numbered 3 and 5); and 4. Resident admission screenings (personnel files numbered 1 and 2); b. Orientation training to the following was not completed before having unsupervised contact with residents: 1. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment (personnel files numbered 3 and 5); 2. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel file numbered 5); and 3. General and special needs, including disability needs of residents and families served (personnel files numbered 3 and 5); c. Orientation to the following was not completed within 45 calendar days of employment: 1. Specific job functions for which the person was hired and meets the needs of the residents the person is serving (personnel file numbered 3); 2. Resident rights (personnel file numbered 5); 3. Rules of conduct and policies and procedures related to discipline of residents serviced (personnel file numbered 3); 4. Psychiatric emergencies and crisis services (personnel files numbered 3 and 5); and 5. Problems and needs of residents with severe emotional disturbance and their families (personnel files numbered 3 and 5); d. The emergency plan was not reviewed at least once every six months (personnel files numbered 1 through 4); and e. Documentation of orientation and ongoing training did not include the name of the entity that provided the training (personnel files numbered 1 through 5). Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure that orientation and ongoing training meets all applicable requirements. Within 30 days of receipt of this order, submit a training plan that identifies the trainings provided to meet both orientation and annual training requirements to demonstrate compliance. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated April 12, 2022 · Correction Order dated February 12, 2021 7. Citation: Minnesota Rules, parts 2960.0660, subpart 1, items A and B. Violation: Two of four personnel files reviewed for requirements governing individual staff development and evaluation did not meet requirements. The individual staff development and evaluation plan was not completed annually for calendar year 2022 (personnel files numbered 1 and 4). Corrective Action Ordered: Immediately and on an ongoing basis, the certificate holder must ensure that staff development and evaluation plans meet all applicable requirements. Repeat Violation: The license holder was cited for a similar violation in the following orders: · Correction Order dated April 12, 2022 · Correction Order dated February 12, 2021 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 Certificate 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 your Licensor 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. Sincerely, Tina Christensen, Human Services Licensor Licensing Division Office of Inspector General 651-431-6610
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