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August 15, 2024 Michelle Murray, Authorized Agent Nexus Mille Lacs Family Healing 505 Highway 169 N Ste. 500 Plymouth, MN 55441 License Number: 1036935 (CRF) Report Number: 202403288, 202403379, 202403986 CORRECTION ORDER Dear Michelle Murray, On May 21, through May 24, 2024, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Nexus Mille Lacs Family Healing located at 407 130th Ave South, Onamia, MN 56359. This review 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 mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, and restrictive techniques standards under Minnesota Rules, part 2960.0710. As a result, DHS is issuing this order which requires you to take the correction 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: There was no documentation of a mental health professional providing weekly face-to-face clinical supervision to all staff providing program services for the following weeks: a. March 5, 2024 (programs 3 and 4); b. March 6, 2024 (program 1); and c. March 20, 2024 (program 1). Rule Violated: Minnesota Rules, part 2960.0630, subpart 2. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that weekly face-to-face clinical supervision meets all applicable requirements. 2. Violation: One of thirteen grievances did not meet requirements. A grievance dated January 22, 2024, did not include investigation findings and resulting action taken by the license holder. Rule Violated: Minnesota Rule, part 2960.0080, subpart 18, item A. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that grievance practices meet all applicable requirements. PERSONNEL FILES 3. Violation: Seven of seven personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways: a. Staff did not receive the following orientation training before having unsupervised contact with residents: i. Emergency procedures (personnel file numbered 14); ii. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents (personnel file numbered 14); iii. General and special needs, including disability needs, of residents and families served (personnel files numbered 7 and 9 through 14); iv. Data practices regulations and issues (personnel files numbered 11 and 13); b. Staff did not receive the following orientation training prior to having direct contact with youth: i. Concepts of trauma-informed care and how to provide services to each youth according to those concepts (personnel files numbered 7 and 13); ii. Culturally competent care (personnel file numbered 7); iii. Racial bias and racism issues (personnel file numbered 7); iv. Health related disabilities (personnel files numbered 7 and 9 through 14) c. Staff did not receive orientation training on the license holders program abuse prevention plan within 72 hours of first providing direct contact services (personnel files numbered 7, 13 and 14); and d. Staff did not receive orientation training on the programs rules of conduct and policies and procedures related to the discipline of residents served during the first 45 days of employment (personnel files numbered 13 and 14). Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 3 and 245A.65, subdivision 3 and Minnesota Rules, part 2960.0100, subpart 3, item A and 2960.0150, subpart 4, item C and 2960.0650, subpart 1, item E. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the orientation and training meets all applicable requirements. Within 30 days of receipt of this order, submit orientation training documentation for two new staff members that demonstrates compliance. 4. Violation: Nine of nine personnel files reviewed for requirements governing ongoing training did not meet requirements. Staff did not receive the following training on an annual basis: a. Vulnerable adult maltreatment reporting for calendar year (CY) 2022 (personnel files numbered 1, 2 and 4) and CY 2023 (personnel file numbered 14); b. The license holders program abuse prevention plan for CY 2022 (personnel files numbered 2 through 6, 8, and 14) and CY 2023 (personnel file numbered 14); c. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel files numbered 1 through 6, 8, 13, and 14); Statute and Rule Violated: Minnesota Statues, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0080, subdivision 14 and 2960.0100, subpart 3, item A. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating personnel numbered 14 has received program abuse prevention plan training, and submit documentation demonstrating that all staff have been trained on all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. RESIDENT FILES 5. Violation: Three of four resident files reviewed for requirements governing resident information did not meet requirements (resident files numbered 1, 2, and 4). There was no documentation in the youth’s file that the license holder recorded and maintained the contact information for all known biological family members and fictive kin of the youth. Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (g). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that resident information meets all applicable requirements. 6. Violation: One of four resident files reviewed for requirements governing admission criteria did not meet requirements (resident file numbered 4). There was no documentation that before or at admission, the license holder examined the placement agency’s information about the resident to determine and document the following: a. Whether the program can meet the residents needs; b. Whether the resident is a danger to the resident’s self or others; and c. 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. 7. Violation: Two of four resident files reviewed for requirements governing admission procedures did not meet requirements in the following ways: a. The license holder did not communicate verbally and in writing to a resident who is capable of understanding the facility’s rules and details of the due process system used in the facility (resident file numbered 2); and b. There was no documentation to demonstrate the that license holder had provided youth with a written copy of the resident’s basic rights information within 24 hours of admission (resident file numbered 4). Rule Violated: Minnesota Rules, part 2960.0080, subpart 4. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meets all applicable requirements. 8. Violation: One resident file reviewed for requirements governing vulnerable adult orientation did not meet requirements (resident file numbered 1). The license holder did not orient a vulnerable adult, within 24 hours of admission to the program, or upon turning 18, to policies and procedures governing maltreatment of vulnerable adults and the internal and external reporting policies, including the telephone number for MAARC. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c). Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult orientation meets all applicable requirements. 9. Violation: One of four resident files reviewed for requirements governing admission screenings did not meet requirements (resident file numbered 2). The screenings did not indicate the degree to which the resident’s family desired to be involved during the resident’s stay at the facility. Rule Violated: Minnesota Rules, part 2960.0070, subpart 5, item D. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission screenings meets all applicable requirements. 10. Violation: One of four resident files reviewed for requirements governing program services did not meet requirements (resident file numbered 1). There was no documentation that the license holder reviewed the emergency plan with the resident at least once every six months. Rule Violated: Minnesota Rules, part 2960.0080, subpart 14. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program services meets all applicable requirements. Violation: Two of four resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways: a. The individual treatment plan (ITP) was not completed within 10 working days of admission (resident file numbered 3); b. The ITP did not include the following required components, when psychotropic medications were administered (resident files numbered 2 and 3): i. 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 would use to monitor and measure changes in the symptoms and behaviors that were to be alleviated by the psychotropic medication.
Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident that demonstrates compliance. 11. Violation: Two of three resident files reviewed for requirements governing service plan reviews did not meet requirements in the following ways: a. There was no documentation that the interdisciplinary team reviewed and evaluated the IAPP as part of the service plan review, using the individual assessment and any reports of abuse relating to the resident (resident file numbered 1); and b. The license holder did not review the resident’s case and treatment plans on a monthly basis for March, 2024 (resident file numbered 3). Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Rules, part 2960.0180, 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 April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service plan reviews meets all applicable requirements. 12. Violation: Two of four resident files reviewed for requirements governing health care did not meet requirements in the following ways: a. The license holder did not document attempts to contact the child’s parent or guardian to seek permission for the facility to administer medication (resident file numbered 4); and b. There was no documentation that the license holder provided a resident who is 18 years of age or older their prescription medication upon discharge (resident file numbered 1). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, items D and F. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that health care meets all applicable requirements. 13. Violation: Two of three resident files reviewed for requirements governing the use of psychotropic medication did not meet requirements (resident files numbered 2 and 3). The license holder did not document the following: a. Monitoring for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication; b. Monthly psychotropic medication review; and c. Data collected since the last review. Rule Violated: Minnesota Rules, part 2960.0620 subpart 2 and subpart 5, item B. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that monitoring the use of psychotropic medication meets all applicable requirements. 14. Violation: Two of three resident files reviewed for requirements governing informed consent for psychotropic medications did not meet requirements (resident files numbered 1 and 2). The informed consent did not include how risks and side effects of the psychotropic medication would be managed. Rule Violated: Minnesota Rules, part 2960.0620, subpart 7, item E. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that informed consent meets all applicable requirements. 15. Violation: Five of five resident files reviewed for requirements governing restrictive procedures did not meet requirements in the following ways: a. Staff did not contact the mental health professional or the facility’s program director to inform them about the use of the physical hold within 30 minutes after initiating the physical hold on June 25, 2023, and July 21, 2023 (resident file numbered 4); b. The staff person who implemented the emergency use of physical holding did not document it’s use immediately after the incident concluded on the following dates: i. November 29, 2022 (resident file numbered 1); ii. April 21, 2024 and April 27, 2024 (resident file numbered 2); iii. June 25, 2023, July 21, 2023, and August 21, 2023 (resident file numbered 4); iv. May 17, 2022, May 25, 2022 and June 16, 2022 (resident file numbered 5); v. January 23, 2024, January 24, 2024 and January 31, 2024 (resident file numbered 3); c. The time the physical hold began and the time the resident was released was not documented for incidents dated June 25, 2023, and July 21, 2023 (resident file numbered 4); and d. The resident’s behavioral change and change in physical status that resulted from the use of the procedure was not documented on January 31, 2024 (resident file numbered 3) Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items E, G, and K. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures meets all applicable requirements. 16. Violation: One of five resident files reviewed for requirements governing the administrative review of restrictive procedures did not meet requirements (resident file numbered 4). The administrative reviews did not indicate whether the procedure was used in accordance with the resident’s treatment plan for incidents dated June 25, 2023, and July 21, 2023. Rule Violated: Minnesota Rules, part 2960.0710, subpart 10, item B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the administrative review of restrictive procedures meets all applicable requirements. 17. Violation: One of three resident files reviewed for requirements governing discharge procedures did not meet requirements (resident file numbered 3). The license holder did not provide the resident with a signed receipt of their personal property inventory upon discharge. Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meets all applicable requirements. 18. Violation: Two of three resident files reviewed for requirements governing transition services plans did not meet requirements in the following ways: a. The plan did not consider the environment into which the resident would return and recommend how the resident may deal with issues and potential challenges within that environment (resident file numbered 4); b. The plan was not developed with input from the resident (resident file numbered 4); c. A copy of the plan was not provided to the resident (resident files numbered 1 and 4); and d. The contents of the transition services plan did not contain treatment needs (resident file numbered 4). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B. Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated April 2, 2021. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plans meets all applicable requirements. 19. Violation: Two of three resident files reviewed for requirements governing aftercare services did not meet requirements (resident files numbered 1 and 4). The program did not provide discharge planning and family-based aftercare support to the youth for at least six months after the youth’s discharge from the program. Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (i). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that aftercare services 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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