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July 26th, 2024 Michelle Murray, Authorized Agent Nexus East Bethel Family Healing 900 189th Avenue Northeast East Bethel, MN 55011 License Number: 1119782 (PRTF) CORRECTION ORDER Dear Michelle Murray: On May 13th, 14th, and 15th 2024, Department of Human Services (DHS) licensors conducted a licensing review at your facility, Nexus East Bethel Family Healing located at 900 189th Avenue NE East Bethel, MN 55011. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Psychiatric Residential Treatment Facilities (PRTF) under the PRTF Variance to Minnesota Rules, chapter 2960. As a result, DHS is issuing this order which requires you to take the corrective action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. 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 ensure that all treatment team members participated in clinical supervision or an ancillary meeting for each calendar week they worked in three of three weeks reviewed. Additionally, the ancillary meetings held during these weeks were not conducted by a clinical supervisor or a mental health practitioner who participated in the weekly meeting: a. February 18, 2024; b. April 21, 2024; and c. May 5, 2024. Rule Violated: Minnesota Variance, section R2960V.13. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision and ancillary meetings meet all applicable requirements. 2. Violation: The license holder’s review of their quality assurance plan did not meet requirements. The following required components have not been reviewed: a. Resident outcomes, including an evaluation of the outcome data to identify ways to improve the effectiveness of the services provided to residents and improve resident outcomes; b. Attaining and evaluating feedback from residents, family members, staff, and referring agencies concerning the services provided; c. Restraint and seclusion data; d. Serious occurrences and other significant incidents, including: i. Determining whether policies and procedures were followed; ii. Evaluating the staff’s response to the serious occurrence and other significant incidents; iii. Assessing what could have prevented the serious occurrence and other significant incidents from occurring; iv. Modifying policies, procedures, training plans, or residents’ individual treatment plans in response to the findings of the review; and e. Self-monitoring of compliance, including the license holder’s actions to improve the program’s compliance with the requirements of this variance. Rule Violated: Minnesota Variance, R2960V.17, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure to conduct a quarterly review of the quality assurance and improvement plan that meets all applicable requirements. 3. Violation: The quarterly review of the patterns of the use of restraint and seclusion did not include the following required components: a. Any patterns or problems indicated by similarities in the duration of the use of a procedure; b. Any injuries that occurred as a result of the use of restraint and seclusion; c. An assessment of opportunities missed to avoid the use of restraint and seclusion; and d. Proposed actions to be taken to minimize the use of restraint and seclusion. Rule Violated: Minnesota Variance, R2960V.11, subpart 5. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the quarterly review of patterns of use or restraint and seclusion includes all applicable requirements. PERSONNEL FILES 4. Violation: SP8 began a position allowing direct contact with persons served by the program on January 15, 2024, and has since had a legal name change. The license holder did not initiate a new background study or notify the commissioner of the name change for SP8. Statute Violated: Minnesota Statutes, section 245C.04, subdivision 7. Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Since the licensing review, the license holder has corrected this violation and no further action is required. 5. Violation: Eight of eight personnel files reviewed for requirements governing orientation trainings did not meet requirements in the following ways: a. There was no documentation to demonstrate the staff person received orientation on the following required topics prior to providing direct contact services: i. The requirements in Minnesota Statutes, section 245A.65, subdivision 3 (personnel files numbered 4 and 5); ii. Minnesota Statutes, section 626.556, subdivisions 2, 3, and 7 (personnel files numbered 4 and 5); iii. Resident rights (personnel files numbered 1 and 4); iv. Emergency procedures (personnel files numbered 2 and 5); v. Resilience and recovery concepts and principles (personnel file numbered 4); vi. Gender based needs (personnel file numbered 4); vii. Resident confidentiality (personnel file numbered 5); and viii. Training related to specific activities and job functions that the staff person will be responsible to carry out (personnel file numbered 4). b. There was no documentation to demonstrate the staff person received the following required trainings within 30 days of providing direct contact services: i. Facility policies and procedures (personnel files numbered 1 through 4); ii. The treatment needs of residents, including psychiatric and co-occurring disorders (personnel files numbered 1 through 5 and 7 through 8); iii. Best practice service delivery (personnel file numbered 4). c. There was no documentation of the credentials of the people who certified the completion of training (personnel files numbered 1 through 8). Rule Violated: Minnesota Variance, R2960V.16, subparts 2 and 6. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of orientation training meets all applicable requirements. Within 30 days receipt of this order, submit orientation training documentation for one staff person that demonstrates compliance. RESIDENT FILES 6. Violation: One of three resident files reviewed for requirements governing resident rights did not meet requirements (resident file numbered 3). There was no documentation to demonstrate the license holder provided the resident’s guardian with a written copy of the resident’s basic rights information within five days of admission. Rule Violated: Minnesota Variance, R2960V.04, subpart 2, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must provide the resident’s parent, legal guardian, or custodian with a written copy of the resident’s basic rights information within five days of admission. 7. Violation: Three of three resident files reviewed for requirements governing individual plans of care did not meet the following requirements: a. The resident’s preliminary plan of care did not include: i. As assessment of needs related to the resident’s health and safety (resident files numbered 1 and 3); ii. At least one treatment goal (resident files numbered 1 through 3); and iii. The resident’s treatment schedule (resident files numbered 1 and 3). b. The resident’s individual plan of care did not include: i. Measurable treatment objectives (resident files numbered 1 through 3); ii. The frequency of the interventions identified (resident file numbered 1); iii. Medication management goals (resident files numbered 1 through 3); and iv. Education about chemical health provided to residents who display issues related to inappropriate chemical use but who do not have a sufficient chemical use history to refer to treatment (resident files numbered 1 and 3); c. The individual plan of care was implemented later than ten days after admission (resident files numbered 1 and 3); d. The multidisciplinary treatment team did not meet to review the resident’s individual plan of care at least once during the first 10 days following admission (resident files numbered 1 and 3) and every 30 days thereafter (resident file numbered 1); and e. The individual plan of care was not signed by the multidisciplinary team member, the medical director, who approved the plan of care (resident file numbered 1). Rule Violated: Minnesota Variance, R2960V.07, subpart 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must follow all requirements governing a resident’s individual plan of care. Within 30 days receipt of this order, submit an individual plan of care that meets all requirements. 8. Violation: One of three resident files reviewed for requirements governing the health screening did not meet requirements (resident file numbered 2). Documentation did not demonstrate that a health screening was completed within 72 hours of admission. Rule Violated: Minnesota Variance, R2960V.08, subpart 2, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of health screenings meet all applicable requirements. 9. Violation: One of three resident files reviewed for requirements governing health care services did not meet requirements (resident filed numbered 1). Documentation did not demonstrate that the license holder maintained accurate and thorough documentation of medical and health records of residents, including significant medical or health related information. Rule Violated: Minnesota Variance, R2960V.08, subpart 2, item G. Corrective Action Required: Immediately and on an ongoing basis, the license holder must meet all requirements related to healthcare services. 10. Violation: Three of three resident files reviewed for requirements governing medication reconciliation did not meet requirements (resident files numbered 1 through 3). There was no documentation to demonstrate medication reconciliation was conducted. Rule Violated: Minnesota Variance, R2960V.08, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure medication reconciliation meets all applicable requirements. Within 30 days receipt of this order, submit documentation of the medication reconciliation process that demonstrates compliances. 11. Violation: Three of three resident files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. The license holder did not obtain written or verbal authorization from the resident’s legal guardian prior to administering medications (resident file numbered 3); b. Documentation did not identify occurrences of a medication not being administered as prescribed (resident files numbered 1 and 3); and c. Standing medication orders were not individualized to the resident; they were not signed by the prescribing practitioner (resident files numbered 1 through 3). Rule Violated: Minnesota Variance, R2960V.08, subpart 4, items A, B and E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must meet all requirements governing medication administration. 12. Violation: Three of three resident files reviewed for requirements governing the use of psychotropic medications did not meet requirements in the following ways: a. The prescribing practitioner did not document the following required components (resident files numbered 1 through 3): i. A description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate; and ii. Data collection methods the license holder must use to monitor and measure changes in symptoms and behaviors that are to be alleviated by the psychotropic medication; b. There was no documentation to demonstrate a prescribing practitioner conducted a psychotropic medication review at least weekly for the first month after admission (resident file numbered 1). Rule Violated: Minnesota Variance, R2960V.08, subpart 6, items B and C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication reviews meet all applicable requirements. Within 30 days receipt of this order, submit documentation of a psychotropic medication review to demonstrate compliance. 13. Violation: Two of two resident files reviewed for requirements governing informed consent for psychotropic medications did not meet requirements in the following ways: a. Informed consent for an antipsychotic medication was not obtained in writing (resident files numbered 1 and 3); b. Informed consent was not obtained by the license holder within 30 days to continue the use of psychotropic medication, after verbal consent expired (resident file numbered 1); and c. There is no documentation that the following information was not provided orally or in writing to the resident and their legal guardian: i. The pharmacological treatment options available (resident files 1 and 3); ii. The commonly known brand name of the psychotropic medication to be used (resident file numbered 1); iii. An explanation that consent may be refused or withdrawn at any time and that the consent expires yearly for written consent (resident file numbered 3); iv. The names, addresses, and phone numbers of appropriate professionals to contact if questions or concerns arise (resident files numbered 1 and 3); and v. The signature of the resident and resident’s legal representative acknowledging they have been talked to about the medication and that they agree to the medication and dosage (resident files numbered 1 and 3). Rule Violated: Minnesota Variance, R2960V.08, subparts 7 and 8. Corrective Action Required: Immediately and on an ongoing basis, the license holder must adhere to all requirements governing obtaining informed consent. 14. Violation: Two of three resident files reviewed for requirements governing monitoring for medication side effects did not meet requirements (resident files numbered 1 and 3). Documentation did not demonstrate that the frequency of side effect monitoring was determined. Rule Violated: Minnesota Variance, R2960V.08, subpart 10. Corrective Action Required: Immediately and on an ongoing basis, the license holder must document and monitor for side effects as determined by the nurse. 15. Violation: Two of two resident files reviewed for requirements governing the use of restrictive procedures did not meet requirements in the following ways: a. The license holder did not conduct a debriefing within 24 hours of the use of restraint on April 4, 2024, and May 10, 2024 (resident file numbered 1); and b. The license holder did not complete an administrative review within three working days after the physical hold, and did not provide the resident with the opportunity to have a legal representative or advocate participate in the debriefing for the following incidents: i. January 29, 2024 (resident file numbered 2); ii. January 21, 2024 (resident file numbered 2); iii. April 19, 2024 (resident file numbered 2); iv. April 4, 2024 (resident file numbered 1); v. April 23, 2024 (resident file numbered 1); and vi. May 10, 2024 (resident file numbered 1). Rule Violated: Minnesota Variance, R2960V.11, subparts 3 and 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must conduct debriefings after all uses of restrictive procedures that follow all timelines and components of the requirement. 16. Violation: One resident file reviewed for requirements governing discharge planning did not meet requirements. There was no documentation to demonstrate the license holder prepared an aftercare plan that addressed the clinical rationale for medications (resident file numbered 2). Rule Violated: Minnesota Variance, R2960V.07, subpart 3, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must develop aftercare plans that meet all requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines 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 the corrective action ordered must be sent to your licensor by email at Tina.Christensen@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Tina Christensen 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: 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 - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6270 or at Hannah.Horsch@state.mn.us. Sincerely, Hannah Horsch, Licensor Licensing Division Office of Inspector General
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