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October 9, 2024 Michelle Murray, Authorized Agent Nexus Family Healing 505 Highway 169 N. STE 500 Plymouth, MN 55441 License Number: 1108377 Dear Michelle Murray: On August 22, 2024, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of the citation in the Correction Order (Attachment A) issued to you by the Department of Human Services on August 8, 2024. You requested reconsideration only of violations b and c of the citation. Violations a and d of the citation are therefore final and not within the scope of this review.
Citation 1: Violation: The license holder did not meet critical incident reporting requirements. The following incidents met the definition of a critical incident and were not submitted to DHS within 10 days of learning of the incident: a. An incident dated July 29, 2023, was submitted on June 2, 2024; b. An incident dated September 1, 2023, was submitted on June 3, 2024; c. An incident dated May 26, 2024, was submitted on June 18, 2024; and d. Two incidents dated July 6, 2024, were submitted on July 27, 2024. Request for Reconsideration. You submitted a letter requesting reconsideration in which you indicate the program was in compliance with the applicable law at the time the citation was issued. With regard to item b, you indicate the program reported the incident on September 26, 2023, and the report sent on June 3, 2024, was a duplicate of the same incident. With regard to item c, you indicate that although you reported the incident to the Office of Ombudsman on June 3, 2024, you believe the incident did not require a critical incident report to DHS because the injury did not require hospitalization or serious medical treatment. You acknowledge that the incident involved a head injury that required medical attention. You submitted supporting documentation.
Reconsideration Determination. Under Minnesota Rules, part 2960.0080, subpart 17, item A, the license holder must report critical incidents and the maltreatment of a resident according to items A to D. Item A requires that the license holder report critical incidents of a serious nature that involve or endanger the life or safety of the resident or others to the commissioner of human services within ten days of the day of the occurrence on forms approved by the commissioner of human services or corrections. The license holder must maintain records of all critical incidents on file in the facility. Under Minnesota Rules, part 2960.0020, subpart 24, “critical incident” means an occurrence which involves a resident and requires the program to make a response that is not part of the program’s ordinary daily routine. Examples of critical incidents include, but are not limited to, suicide, attempted suicide, homicide, death of a resident, injury that is either life-threatening or requires medical treatment, fire which requires fire department response, alleged maltreatment of a resident, assault of a resident, assault by a resident, client-to-client sexual contact, or other act or situation which would require a response by law enforcement, the fire department, an ambulance, or another emergency response provider. With regard to violation b, there is no record of the report being submitted until June 3, 2024, and no documentation of an earlier report was provided. Even if the report had been submitted on September 26, 2023, it would not have met the requirements of the rule. The incident occurred on September 1, 2023, which would have been twenty-five days prior to the date of the report, and the rule requires that critical incidents be reported within ten days of the occurrence. With regard to violation c, you acknowledge the incident involved an injury that required medical attention, and the definition of “critical incident” includes, but is not limited to, an injury that “requires medical treatment.” The definition of “critical incident” means an occurrence which requires the program to make a response that is not part of the program’s ordinary daily routine. According to the Critical Incident Reporting Form you submitted on June 18, 2024, the individual involved in the incident sustained a head injury and was assessed via a telehealth visit with an emergency room physician. Also, an email from the program to DHS dated June 18, 2024, indicated the program would follow up with a critical incident report. There is therefore sufficient evidence to support the violations and they are affirmed, with the modification that the correct authority for the citation is Minnesota Rules, part 2960.0080, item A, and Minnesota Rules, part 2960.0020, subpart 24. The correction order incorrectly cited Minnesota Statutes, section 245I.13 as the authority for the citation. Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the citation, and it is affirmed. This is a final agency decision. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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