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September 30, 2024 Marshall Smith, Authorized Agent Commissioner of Department of Human Services 444 Lafayette Road North Saint Paul, MN 55164 License Number: 801558 Report Number: 202300449 202302880 202304805 CORRECTION ORDER Dear Marshall Smith: A Department of Human Services (DHS) licensor conducted a licensing investigation at your facility, Minnesota Security Hospital dba Forensic Mental Health Program, located at 100 Freeman Drive, Saint Peter, MN 56082 This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of secure mental health treatment services under MSH Variance to Minnesota Rules, parts 9520.0500 to 9520.0690 (Rule 36). 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 did not follow licensing rules and statutes, as described below. Individual File 1. Violation: One individual file was reviewed for requirements governing abuse prevention plans (C1) and did not meet requirements. Individual abuse prevention plans dated November 30, 2023; February 24, 2023; April 5, 2023, April 19, 2023; May 23, 2023; and June 16, 2023; Behavior Plans dated December 16, 2022; March 1, 2023; and April 4, 2023; Support Plans dated February 24, 2023; April 19, 2023; and May 23, 2023; Treatment Plans dated February 21, 2023 and April 17, 2023; and Foreign Body Ingestion Treatment Plan addendum were all reviewed for risk reduction measures related to foreign body ingestion and inhalation. None of the plans reviewed included risk reduction measures to address the individuals access to peers’ belongings within the individual’s environment. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) and Minnesota Variance, part MSH.0004, subpart 6, items A and B. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure abuse prevention plans meet all applicable 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 ginny.benson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Ginny Benson 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 651-431-6957 or at ginny.benson@state.mn.us Sincerely, Ginny Benson, Senior Licensor Licensing Division Office of Inspector General
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